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INTRODUCTION: Selective fetal growth restriction (sFGR) in monochorionic twin pregnancy, defined as an estimated fetal weight (EFW) of one twin <10th centile and EFW discordance ≥25%, is associated with stillbirth and neurodisability for both twins. The condition poses unique management difficulties: on the one hand, continuation of the pregnancy carries a risk of death of the smaller twin, with a high risk of co-twin demise (40%) or co-twin neurological sequelae (30%). On the other, early delivery to prevent the death of the smaller twin may expose the larger twin to prematurity, with the associated risks of long-term physical, emotional and financial costs from neurodisability, such as cerebral palsy.When there is severe and early sFGR, before viability, delivery is not an option. In this scenario, there are currently three main management options: (1) expectant management, (2) selective termination of the smaller twin and (3) placental laser photocoagulation of interconnecting vessels. These management options have never been investigated in a randomised controlled trial (RCT). The best management option is unknown, and there are many challenges for a potential RCT. These include the rarity of the condition resulting in a small number of eligible pregnancies, uncertainty about whether pregnant women will agree to participate in such a trial and whether they will agree to be randomised to expectant management or active fetal intervention, and the challenges of robust and long-term outcome measures. Therefore, the main objective of the FERN study is to assess the feasibility of conducting an RCT of active intervention vs expectant management in monochorionic twin pregnancies with early-onset (prior to 24 weeks) sFGR. METHODS AND ANALYSIS: The FERN study is a prospective mixed-methods feasibility study. The primary objective is to recommend whether an RCT of intervention vs expectant management of sFGR in monochorionic twin pregnancy is feasible by exploring women's preference, clinician's preference, current practice and equipoise and numbers of cases. To achieve this, we propose three distinct work packages (WPs). WP1: A Prospective UK Multicentre Study, WP2A: a Qualitative Study Exploring Parents' and Clinicians' Views and WP3: a Consensus Development to Determine Feasibility of a Trial. Eligible pregnancies will be recruited to WP1 and WP2, which will run concurrently. The results of these two WPs will be used in WP3 to develop consensus on a future definitive study. The duration of the study will be 53 months, composed of 10 months of setup, 39 months of recruitment, 42 months of data collection, and 5 months of data analysis, report writing and recommendations. The pragmatic sample size for WP1 is 100 monochorionic twin pregnancies with sFGR. For WP2, interviews will be conducted until data saturation and sample variance are achieved, that is, when no new major themes are being discovered. Based on previous similar pilot studies, this is anticipated to be approximately 15-25 interviews in both the parent and clinician groups. Engagement of at least 50 UK clinicians is planned for WP3. ETHICS AND DISSEMINATION: This study has received ethical approval from the Health Research Authority (HRA) South West-Cornwall and Plymouth Ethics Committee (REC reference 20/SW/0156, IRAS ID 286337). All participating sites will undergo site-specific approvals for assessment of capacity and capability by the HRA. The results of this study will be published in peer-reviewed journals and presented at national and international conferences. The results from the FERN project will be used to inform future studies. TRIAL REGISTRATION NUMBER: This study is included in the ISRCTN Registry (ISRCTN16879394) and the NIHR Central Portfolio Management System (CPMS), CRN: Reproductive Health and Childbirth Specialty (UKCRN reference 47201).
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Estudios de Factibilidad , Retardo del Crecimiento Fetal , Embarazo Gemelar , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Femenino , Embarazo , Retardo del Crecimiento Fetal/terapia , Estudios Prospectivos , Gemelos Monocigóticos , Espera Vigilante , Recién NacidoRESUMEN
OBJECTIVE: To identify current practices in the management of selective fetal growth restriction (sFGR) in monochorionic diamniotic (MCDA) twin pregnancies. DESIGN: Cross-sectional survey. SETTING: International. POPULATION: Clinicians involved in the management of MCDA twin pregnancies with sFGR. METHODS: A structured, self-administered survey. MAIN OUTCOME MEASURES: Clinical practices and attitudes to diagnostic criteria and management strategies. RESULTS: Overall, 62.8% (113/180) of clinicians completed the survey; of which, 66.4% (75/113) of the respondents reported that they would use an estimated fetal weight (EFW) of <10th centile for the smaller twin and an inter-twin EFW discordance of >25% for the diagnosis of sFGR. For early-onset type I sFGR, 79.8% (75/94) of respondents expressed that expectant management would be their routine practice. On the other hand, for early-onset type II and type III sFGR, 19.3% (17/88) and 35.7% (30/84) of respondents would manage these pregnancies expectantly, whereas 71.6% (63/88) and 57.1% (48/84) would refer these pregnancies to a fetal intervention centre or would offer fetal intervention for type II and type III cases, respectively. Moreover, 39.0% (16/41) of the respondents would consider fetoscopic laser surgery (FLS) for early-onset type I sFGR, whereas 41.5% (17/41) would offer either FLS or selective feticide, and 12.2% (5/41) would exclusively offer selective feticide. For early-onset type II and type III sFGR cases, 25.9% (21/81) and 31.4% (22/70) would exclusively offer FLS, respectively, whereas 33.3% (27/81) and 32.9% (23/70) would exclusively offer selective feticide. CONCLUSIONS: There is significant variation in clinician practices and attitudes towards the management of early-onset sFGR in MCDA twin pregnancies, especially for type II and type III cases, highlighting the need for high-level evidence to guide management.
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Background: Isolated fetal ventriculomegaly can have a range of consequences, ranging from mild neurodevelopmental delay to perinatal death; the extent of these consequences often depend on the severity of ventriculomegaly. This systematic review and meta-analysis aims to investigate the impact of the degree of ventricular dilatation on the risk of neurodevelopmental delay and adverse perinatal outcomes in fetuses diagnosed with isolated fetal ventriculomegaly from gestational week 15 onwards. Methods: PubMed, Embase, Scopus and the Cochrane Library were searched electronically to identify studies investigating the prognosis of mild and/or severe isolated fetal ventriculomegaly. Articles were included if they reported neurodevelopmental or perinatal outcomes in fetuses prenatally diagnosed with isolated fetal ventriculomegaly from week 15 of gestation and onwards. Studies were excluded if they reported on non-isolated ventriculomegaly (IVM), failed to specify the degree of ventriculomegaly, were non-English papers, animal studies or published outside of the 21-year period of interest. Study quality was assessed by two independent reviewers using a modified version of the Newcastle-Ottawa Quality Assessment Scale. Ventriculomegaly was defined as either mild or severe when ventricular diameter measured as 10-15 or >15 mm, respectively. Meta-analyses were conducted for adverse neurodevelopmental outcome, intrauterine fetal demise and infant mortality. Results: Following the removal of duplicates, the search yielded 2,452 citations, of which 23 studies were included and 8 were eligible for meta-analysis. There were 767 and 347 cases of mild and severe isolated fetal ventriculomegaly, respectively. Adverse outcomes were consistently reported at a higher rate in severe cases than mild. The relative risks of adverse neurodevelopmental outcome, intrauterine fetal demise and infant mortality were 4.24 [95% confidence interval (CI): 2.46-7.30], 4.46 (95% CI: 1.64-12.11) and 6.02 (95% CI: 1.73-21.00), respectively, upon comparison of mild versus severe cases of isolated fetal ventriculomegaly. Conclusions: The likelihood of adverse neurodevelopmental and perinatal outcomes, including intrauterine and infant mortality, is increased in severe isolated fetal ventriculomegaly compared to mild isolated fetal ventriculomegaly.
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OBJECTIVES: To review systematically the quality, readability and credibility of English language webpages offering patient information on fetal growth restriction. STUDY DESIGN: A systematic review of patient information was undertaken on Google with location services and browser history disabled. Websites from the first page were included providing they gave at least 300 words of health information on fetal growth restriction aimed at patients. Validated assessment of readability, credibility and quality were undertaken. An accuracy assessment was performed based on international guidance. Characteristics were tabulated. RESULTS: Thirty-one websites including 30 different texts were included. No pages had a reading age of 11 years or less, none were credible, and only one was of high quality. Median accuracy rating was 9/24. CONCLUSION: Patients cannot rely on Google as a source of information on fetal growth restriction. As well as being difficult to read, information tends to be low quality, low accuracy and not credible. Healthcare professionals must consider how to enable access to high-quality patient information and give time for discussion of information patients have found: failure to do so may disenfranchise patients.
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Información de Salud al Consumidor , Femenino , Humanos , Niño , Motor de Búsqueda , Retardo del Crecimiento Fetal , Comprensión , Personal de Salud , InternetRESUMEN
BACKGROUND: The mainstay of assessment of the fetal lungs in clinical practice is via evaluation of pulmonary size, primarily using 2D ultrasound and more recently with anatomical magnetic resonance imaging. The emergence of advanced magnetic resonance techniques such as T2* relaxometry in combination with the latest motion correction post-processing tools now facilitates assessment of the metabolic activity or perfusion of fetal pulmonary tissue in vivo. OBJECTIVE: This study aimed to characterize normal pulmonary development using T2* relaxometry, accounting for fetal motion across gestation. METHODS: Datasets from women with uncomplicated pregnancies that delivered at term, were analyzed. All subjects had undergone T2-weighted imaging and T2* relaxometry on a Phillips 3T magnetic resonance imaging system antenatally. T2* relaxometry of the fetal thorax was performed using a gradient echo single-shot echo planar imaging sequence. Following correction for fetal motion using slice-to-volume reconstruction, T2* maps were generated using in-house pipelines. Lungs were manually segmented and mean T2* values calculated for the right and left lungs individually, and for both lungs combined. Lung volumes were generated from the segmented images, and the right and left lungs, as well as both lungs combined were assessed. RESULTS: Eighty-seven datasets were suitable for analysis. The mean gestation at scan was 29.9±4.3 weeks (range: 20.6-38.3) and mean gestation at delivery was 40±1.2 weeks (range: 37.1-42.4). Mean T2* values of the lungs increased over gestation for right and left lungs individually and for both lungs assessed together (P=.003; P=.04; P=.003, respectively). Right, left, and total lung volumes were also strongly correlated with increasing gestational age (P<.001 in all cases). CONCLUSION: This large study assessed developing lungs using T2* imaging across a wide gestational age range. Mean T2* values increased with gestational age, which may reflect increasing perfusion and metabolic requirements and alterations in tissue composition as gestation advances. In the future, evaluation of findings in fetuses with conditions known to be associated with pulmonary morbidity may lead to enhanced prognostication antenatally, consequently improving counseling and perinatal care planning.
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Pulmón , Imagen por Resonancia Magnética , Embarazo , Femenino , Humanos , Imagen por Resonancia Magnética/métodos , Pulmón/diagnóstico por imagen , Edad GestacionalRESUMEN
BACKGROUND: Multiple sclerosis (MS) is frequently diagnosed in people of reproductive age, many of whom will become pregnant following diagnosis. Although many women report an improvement in symptoms and relapses during pregnancy, symptoms such as fatigue and spasticity are commonly reported and can worsen. Prescribing medications during pregnancy and breastfeeding presents unique challenges and guidance on the use of symptomatic therapies is limited. OBJECTIVES: This paper aims to provide a consensus on the current evidence base to facilitate informed decision-making and optimise pre-conception counselling. METHODS: A list of most commonly prescribed medications for symptom management in MS was created using pregnancy and MS-related READ codes in the Welsh GP Dataset, followed by a review by MS neurologists. RESULTS: A final list of 24 medications was generated for review. Searches were performed on each medication, and evidence graded using standardised criteria. Evidence-based recommendations were developed and distributed to experts in the field and revised according to feedback using modified Delphi criteria. CONCLUSIONS: Our guidelines provide evidence-based recommendations on the safety of symptomatic therapies during pregnancy and breastfeeding for general practitioners and specialist teams working with people with MS who are hoping to embark on pregnancy or are currently pregnant. Individual risk-benefit ratios should be considered during pre-conception counselling to optimise symptom burden and minimise harm to both parent and child.
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Esclerosis Múltiple , Embarazo , Niño , Humanos , Femenino , Esclerosis Múltiple/terapia , Lactancia Materna , Consenso , Técnica Delphi , Espasticidad MuscularRESUMEN
BACKGROUND: Twin anemia polycythemia sequence is a rare complication in monochorionic twin pregnancy. CASE PRESENTATION: We describe a case of dichorionic twin pregnancy presenting with suspected twin anemia polycythemia sequence. A 31-year-old White female, on her third pregnancy, had a routine ultrasound scan at 12 weeks gestation, which demonstrated a dichorionic twin pregnancy with one placenta located in the anterior wall and the other in the posterior wall of the uterus. At 21 weeks, a scan demonstrated a 24% growth discordance between the two fetuses with normal Doppler studies and amniotic fluid. At 27 weeks, one twin showed signs of anemia and the other polycythemia; the fetal middle cerebral artery peak systolic velocity was high in the anemic fetus and low in the polycythemic twin (1.8 and 0.5 multiples of the median). An intrauterine blood transfusion was carried out and this increased the fetal hemoglobin concentration in the anemic twin from 3.5 to 12.5 g/dL. At 29 weeks, delivery by cesarean section was carried out because of evidence from middle cerebral artery peak systolic velocity of recurrence of anemia in one twin and worsening polycythemia in the co-twin; at birth the hemoglobin concentrations were 5.6 and 24.9 g/dL, respectively. Histopathological examination confirmed dichorionicity with no communicating vessels between the two placentas. CONCLUSIONS: This is the first case of twin anemia polycythemia sequence in a dichorionic, diamniotic twin pregnancy where intrauterine blood transfusion was used to prolong the pregnancy by almost 2 weeks in a "twin anemia polycythemia sequence-like" setting.
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Anemia , Transfusión Feto-Fetal , Policitemia , Recién Nacido , Embarazo , Humanos , Femenino , Adulto , Embarazo Gemelar , Transfusión Feto-Fetal/complicaciones , Transfusión Feto-Fetal/diagnóstico por imagen , Cesárea/efectos adversos , Policitemia/complicaciones , Policitemia/diagnóstico por imagen , Gemelos Monocigóticos , Ultrasonografía Prenatal/efectos adversos , Anemia/etiologíaRESUMEN
Background: Chronic histiocytic intervillositis (CHI) is a rare placental lesion with a high recurrence rate and poor perinatal outcomes. There are currently limited guidelines regarding the diagnosis of this condition in the index pregnancy and treatment where recurrence is suspected. Objective: The primary objective of this systematic review and meta-analysis was to determine the perinatal outcomes of pregnancies affected by chronic histiocytic intervillositis and to what extent they can be improved with treatment. The secondary objective was to assess the relationship between CHI lesion severity and pregnancy loss. Methods: A systematic search of Ovid Embase, Web of Science, Science Direct, PubMed, Ovid Medline, Google Scholar and CINAHL was carried out. Case reports, cohort, case-control and randomised controlled trials (RCT) detailing the perinatal outcomes of CHI pregnancies, both treated and untreated, were included. Results: No RCTs were identified. However, in a review population of 659 pregnancies, with additional 7 in case reports, CHI treatments included aspirin, prednisone, prednisolone, low molecular weight heparin (LMWH), hydroxychloroquine and adalimumab. A descriptive synthesis of data found mixed results for treatments in relation to live birth, miscarriage and fetal growth restriction outcomes. Furthermore, quantitative synthesis of 38 pregnancies revealed a non-significant improvement in live birth rate with CHI targeted treatment (OR 1.79 [95% CI 0.33-9.61] (p=0.50), while meta-analysis of CHI severity in line with pregnancy loss, in a sample of 231 pregnancies, revealed lower odds of pregnancy loss with less severe lesions (OR: 0.17 [0.03-0.80], p=0.03). Conclusions: This systematic review and meta-analysis reinforce notions surrounding the insufficient evidence for CHI treatment. It also strengthens previous hypotheses detailing the positive association between CHI lesion severity and odds of pregnancy loss. Aspirin, LMWH, prednisolone, hydroxychloroquine and adalimumab are candidates with varying levels of weak to moderate evidence supporting their use. Further prospective research is required to obtain robust evidence pertaining to treatment safety and efficacy and optimal drug regimes. Systematic Review Registration: [website], identifier CRD42021237604.
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Aborto Espontáneo , Hidroxicloroquina , Adalimumab , Aspirina/uso terapéutico , Femenino , Heparina de Bajo-Peso-Molecular/uso terapéutico , Humanos , Prednisolona , EmbarazoRESUMEN
Antenatal diagnosis of abnormal pulmonary development has improved significantly over recent years because of progress in imaging techniques. Two-dimensional ultrasound is the mainstay of investigation of pulmonary pathology during pregnancy, providing good prognostication in conditions such as congenital diaphragmatic hernia; however, it is less validated in other high-risk groups such as those with congenital pulmonary airway malformation or preterm premature rupture of membranes. Three-dimensional assessment of lung volume and size is now possible using ultrasound or magnetic resonance imaging; however, the use of these techniques is still limited because of unpredictable fetal motion, and such tools have also been inadequately validated in high-risk populations other than those with congenital diaphragmatic hernia. The advent of advanced, functional magnetic resonance imaging techniques such as diffusion and T2* imaging, and the development of postprocessing pipelines that facilitate motion correction, have enabled not only more accurate evaluation of pulmonary size, but also assessment of tissue microstructure and perfusion. In the future, fetal magnetic resonance imaging may have an increasing role in the prognostication of pulmonary abnormalities and in monitoring current and future antenatal therapies to enhance lung development. This review aims to examine the current imaging methods available for assessment of antenatal lung development and to outline possible future directions.
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Hernias Diafragmáticas Congénitas , Enfermedades Pulmonares , Femenino , Hernias Diafragmáticas Congénitas/diagnóstico por imagen , Hernias Diafragmáticas Congénitas/patología , Humanos , Recién Nacido , Pulmón/diagnóstico por imagen , Enfermedades Pulmonares/patología , Mediciones del Volumen Pulmonar/métodos , Embarazo , Diagnóstico PrenatalRESUMEN
INTRODUCTION: Preterm prelabor rupture of membranes (PPROM) complicates 3% of pregnancies in the UK. Where delivery does not occur spontaneously, expectant management until 37 weeks of gestation is advocated, unless signs of maternal infection develop. However, clinical presentation of maternal infection can be a late sign and injurious fetal inflammatory responses may already have been activated. There is therefore a need for more sensitive markers to aid optimal timing of interventions. At present there is no non-invasive test in clinical practice to assess for infection in the fetal compartment and definitive diagnosis of chorioamnionitis is by histological assessment of the placenta after delivery. This study presents comprehensive functional placental magnetic resonance imaging (MRI) quantification, already used in other organ systems, to assess for infection/inflammation, in women with and without PPROM aiming to explore its use as a biomarker for inflammation within the feto-placental compartment in vivo. MATERIAL AND METHODS: Placental MRI scans were performed in a cohort of 12 women (with one having two scans) with PPROM before 34 weeks of gestation (selected because of their high risk of infection), and in a control group of 87 women. Functional placental assessment was performed with magnetic resonance techniques sensitive to changes in the microstructure (diffusion) and tissue composition (relaxometry), with quantification performed both over the entire organ and in regions of interest between the basal and chorionic plate. Placental histology was analyzed after delivery where available. RESULTS: Normative evolution of functional magnetic resonance biomarkers over gestation was studied. Cases of inflammation, as assessed by histological presence of chorioamnionitis, and umbilical cord vasculitis with or without funisitis, were associated with lower T2* (mean T2* at 30 weeks 50 ms compared with 58 ms in controls) and higher fractional anisotropy (mean at 30 weeks 0.55 compared with 0.45 in controls). These differences did not reach significance and there was substantial heterogeneity both in T2* and Apparent Diffusivitiy across the cohort. CONCLUSIONS: This first exploration of functional placental assessment in a cohort of women with PPROM demonstrates that functional placental MRI can reveal a range of placental changes associated with inflammatory processes. It is a promising tool to gain information and in the future to identify inflammation in vivo, and could therefore assist in improving optimal timing for interventions designed to prevent fetal injury.
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Rotura Prematura de Membranas Fetales/diagnóstico por imagen , Diagnóstico Prenatal , Adulto , Femenino , Humanos , Londres , Imagen por Resonancia Magnética , Proyectos Piloto , Embarazo , Estudios Prospectivos , Centros de Atención TerciariaRESUMEN
OBJECTIVES: The fetal thymus gland has been shown to involute in response to intrauterine infection, and therefore could be used as a non-invasive marker of fetal compartment infection. The objective of this study was to evaluate how accurately 2D ultrasound-derived measurements of the fetal thymus reflect the 3D volume of the gland derived from motion corrected MRI images. STUDY DESIGN: A retrospective study was performed using paired ultrasound and MRI datasets from the iFIND project (http://www.ifindproject.com). To obtain 3D volumetry of the thymus gland, T2-weighted single shot turbo spin echo (ssTSE) sequences of the fetal thorax were acquired. Thymus volumes were manually segmented from deformable slice-to-volume reconstructed images. To obtain 2D ultrasound measurements, previously stored fetal cine loops were used and measurements obtained at the 3-vessel-view (3VV) and 3-vessel-trachea view (3VT): anterior-posterior diameter (APD), intrathoracic diameter (ITD), transverse diameter (TD), perimeter and 3-vessel-edge (3VE). Inter-observer and intra-observer reliability (ICC) was calculated for both MRI and ultrasound measurements. Pearson correlation coefficients (PCC) were used to compare 2D-parameters with acceptable ICC to TV. RESULTS: 38 participants were identified. Adequate visualisation was possible on 37 MRI scans and 31 ultrasound scans. Of the 30 datasets where both MRI and ultrasound data were available, MRI had good interobserver reliability (ICC 0.964) and all ultrasound 3VV 2D-parameters and 3VT 3VE had acceptable ICC (>0.75). Four 2D parameters were reflective of the 3D thymus volume: 3VV TD râ¯=â¯0.540 (Pâ¯=â¯0.002); 3VV perimeter râ¯=â¯0.446 (Pâ¯=â¯0.013); 3VV APD râ¯=â¯0.435 (Pâ¯=â¯0.110) and 3VT TD râ¯=â¯0.544 (Pâ¯=â¯0.002). CONCLUSIONS: MRI appeared superior to ultrasound for visualization of the thymus gland and reproducibility of measurements. Three 2D US parameters, 3VV TD, perimeter and 3VT APD, correlated well with TV. Therefore, these represent a more accurate reflection of the true size of the gland than other 2D measurements, where MRI is not available.
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Timo , Ultrasonografía Prenatal , Femenino , Edad Gestacional , Humanos , Imagenología Tridimensional , Imagen por Resonancia Magnética , Embarazo , Reproducibilidad de los Resultados , Estudios Retrospectivos , Timo/diagnóstico por imagenRESUMEN
OBJECTIVES: To identify variation in the antenatal management of multiple pregnancy. The UK has 10,000 twin pregnancies per year. There is established guidance on the management of dichorionic (DC) and monochorionic (MC) twin pregnancy from both the RCOG and NICE, however it is likely that the provision and practice of multiple pregnancy management varies amongst units. DESIGN: Questionnaires were posted to 151 UK maternity units in 3 rounds from May to November 2019. RESULTS: 60 responses were received (range 11,500 to 501 deliveries), with annual multiple pregnancy rates of 190 to 4. 25 % of units did not offer a dedicated twin clinic and less than 15 % of units provided dedicated multiple pregnancy midwifery staff for intrapartum and postnatal care. Cervical length screening was performed in 24 % of units with 84 % of units offering treatment for a short cervix. 15 % of units prescribed Aspirin to all multiples, 47 % prescribing 75 mg and 43 % 150 mg. Monitoring of MC pregnancies varied with 18 % of units not measuring Middle Cerebral Artery and 29 % Ductus Venosus Dopplers. Mean caesarean section rate was 61.7 %. Delivery was offered from 37 weeks in 93 % of DC twins and from 36 weeks in 90 % MC twins. 5% of MC twins were given non labouring prophylactic antenatal steroids. CONCLUSION: Despite well-established national guidance for twin pregnancy management there remains a wide variation in practice among units in the provision and antenatal management of multiple pregnancies throughout the UK. The exact reasons for this variation require further exploration.
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Cesárea , Gemelos Monocigóticos , Femenino , Edad Gestacional , Humanos , Embarazo , Embarazo Gemelar , Encuestas y Cuestionarios , Reino UnidoAsunto(s)
Desprendimiento Prematuro de la Placenta , COVID-19 , Cesárea/métodos , Sufrimiento Fetal , Complicaciones Infecciosas del Embarazo , SARS-CoV-2/aislamiento & purificación , Desprendimiento Prematuro de la Placenta/diagnóstico , Desprendimiento Prematuro de la Placenta/fisiopatología , Desprendimiento Prematuro de la Placenta/terapia , Adulto , COVID-19/complicaciones , COVID-19/diagnóstico , COVID-19/fisiopatología , Servicios Médicos de Urgencia/métodos , Femenino , Sufrimiento Fetal/diagnóstico , Sufrimiento Fetal/etiología , Sufrimiento Fetal/terapia , Edad Gestacional , Humanos , Recién Nacido , Transmisión Vertical de Enfermedad Infecciosa/prevención & control , Manejo de Atención al Paciente/métodos , Embarazo , Complicaciones Infecciosas del Embarazo/diagnóstico , Complicaciones Infecciosas del Embarazo/fisiopatología , Complicaciones Infecciosas del Embarazo/virología , Resultado del Embarazo , Embarazo Gemelar , Resultado del Tratamiento , Hemorragia Uterina/diagnóstico , Hemorragia Uterina/etiologíaRESUMEN
OBJECTIVES: Maternal sickle cell disease (SCD) and multiple gestations are well known separately as causes of high-risk pregnancies, however, there is sparse information available on maternal and perinatal outcome when both conditions occur together. This case series describes the outcomes of women with maternal SCD and twin pregnancy in the largest single-center case series to date. METHODS: Retrospective identification of all twin pregnancies in maternal SCD patients between 2006 and 2016 at Guy's and St. Thomas' Hospital, United Kingdom Results: Eight women were included: seven with HbSS and one with HbSC. Our cohort experienced common SCD-related and pregnancy-related complications such as painful vaso-occlusive crises (VOC), acute chest syndrome (ACS), and pre-eclampsia and less common complications such as peri-partum cardiomyopathy and delayed hemolytic transfusion reaction. Only two out of eight women had relatively uncomplicated pregnancies. Seven out of eight women required transfusion antenatally and there was no maternal or perinatal mortality. A review of the available literature highlighted the lack of available information on this uncommon cohort. It was evident that outcomes have improved over the years, where historical studies demonstrate higher rates of maternal and perinatal mortality. DISCUSSION: The antenatal and postnatal complications described in our study and literature review highlights the significant morbidity and mortality associated with these high-risk pregnancies. CONCLUSION: Our case series highlights the advantage of closer monitoring and comprehensive multidisciplinary care in delivering improved clinical outcomes.
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Síndrome Torácico Agudo/terapia , Transfusión Sanguínea , Preeclampsia/terapia , Complicaciones Hematológicas del Embarazo/terapia , Embarazo Gemelar , Síndrome Torácico Agudo/patología , Síndrome Torácico Agudo/fisiopatología , Adulto , Femenino , Humanos , Preeclampsia/patología , Preeclampsia/fisiopatología , Embarazo , Complicaciones Hematológicas del Embarazo/patología , Complicaciones Hematológicas del Embarazo/fisiopatologíaRESUMEN
OBJECTIVE: To examine maternal serum levels of retinol-binding protein-4 (RBP4) at 11-13 weeks' gestation in normal and pathological pregnancies. METHODS: Serum RBP4 at 11-13 weeks was measured in 480 singleton pregnancies, including 240 with normal outcome, 60 that subsequently developed preeclampsia (PE), 60 that developed gestational diabetes mellitus (GDM), 60 that delivered large for gestational age (LGA) neonates and 60 that delivered small (SGA) neonates. The values in each adverse pregnancy outcome group were compared to those of normal pregnancies. RESULTS: Serum concentration of RBP4 was not significantly different in women who subsequently developed PE (p=0.925), or GDM (p=0.074), or had pregnancies that led to delivery to SGA (p=0.085), LGA (p=0.332) neonates. CONCLUSION: Maternal serum RBP4 in the first trimester is not significantly altered in pathological pregnancies.
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Complicaciones del Embarazo/sangre , Embarazo/sangre , Proteínas Plasmáticas de Unión al Retinol/análisis , Adulto , Peso al Nacer , Femenino , Humanos , Recién Nacido , Recién Nacido Pequeño para la Edad Gestacional , Preeclampsia/sangre , Preeclampsia/fisiopatología , Complicaciones del Embarazo/fisiopatología , Primer Trimestre del Embarazo , Embarazo en Diabéticas/sangre , Embarazo en Diabéticas/fisiopatología , Estudios Prospectivos , Valores de ReferenciaRESUMEN
Cardiac disease is the leading cause of maternal mortality in the UK. The major causes of cardiac deaths in pregnancy include cardiomyopathy, myocardial infarction, ischaemic heart disease and dissection of the thoracic aorta. With increasing numbers of migrant women in the UK, rheumatic heart disease in pregnancy has also re-emerged. Women with uncorrected congenital heart disease and those who have undergone corrective or palliative surgery may have complicated pregnancies. Women with metal prosthetic valves face difficult decisions regarding anticoagulation in pregnancy and have an increased risk of haemorrhage. Not all women with significant heart disease are able to meet the increased physiological demands of pregnancy. The care of pregnant women with heart disease thus requires a multidisciplinary approach, involving obstetricians, cardiologists and anaesthetists. This allows appropriate surveillance of maternal and fetal wellbeing, as well as planning and documentation of the management of elective and emergency delivery. This review discusses common cardiac conditions encountered in pregnancy and their antenatal and intrapartum management.
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Cardiopatías , Complicaciones Cardiovasculares del Embarazo , Femenino , Asesoramiento Genético , Cardiopatías/diagnóstico , Cardiopatías/etiología , Cardiopatías/terapia , Humanos , Embarazo , Complicaciones Cardiovasculares del Embarazo/diagnóstico , Complicaciones Cardiovasculares del Embarazo/etiología , Complicaciones Cardiovasculares del Embarazo/terapia , Atención Prenatal , Diagnóstico Prenatal , Factores de RiesgoRESUMEN
The objective was to examine maternal serum levels of resistin at 11 to 13 weeks' gestation in normal and pathological pregnancies. Serum resistin, pregnancy-associated plasma protein A (PAPP-A), and uterine artery pulsatility index (PI) at 11 to 13 weeks were measured in 480 singleton pregnancies, including 240 with normal outcome, 60 that subsequently developed preeclampsia (PE), 60 that developed gestational diabetes mellitus (GDM), 60 that delivered large for gestational age (LGA) neonates, and 60 that delivered small for gestational age (SGA) neonates. Each value in both the normal and pathological outcome groups was expressed as a multiple of the expected normal median (MoM), and the median MoM values in the outcome groups were compared. In the PE group, compared with the controls, there were an increase in median resistin (1.22 MoM, P = .003) and uterine artery PI (1.25 MoM, P < .0001) and a decrease in serum PAPP-A (0.72, P < .0001). There was no significant association between serum resistin with either uterine artery PI (P = .415) or serum PAPP-A (P = .290). In the SGA, LGA, and GDM groups, serum resistin MoM was not significantly different from that of the controls (P = .415, P = .702, and P = .549, respectively). In pregnancies that develop PE, maternal serum resistin concentration at 11 to 13 weeks is increased in a manner not related to altered placental perfusion or function. In pregnancies complicated by the development of GDM or delivery of SGA or LGA neonates, serum resistin is not significantly altered.
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Complicaciones del Embarazo/sangre , Resistina/sangre , Adulto , Peso al Nacer/fisiología , Diabetes Gestacional/sangre , Ensayo de Inmunoadsorción Enzimática , Femenino , Edad Gestacional , Humanos , Recién Nacido , Recién Nacido Pequeño para la Edad Gestacional , Placentación/fisiología , Preeclampsia/sangre , Embarazo , Proteína Plasmática A Asociada al Embarazo/metabolismo , Valores de ReferenciaRESUMEN
OBJECTIVE: To examine the potential role of maternal serum level of adiponectin in the first trimester of pregnancy in the prediction of neonatal macrosomia. METHODS: Maternal serum adiponectin concentration was measured in a case-control study of singleton pregnancies at 11 to 13 weeks' gestation, which included 50 cases that subsequently delivered macrosomic neonates with birth weight above the 95th percentile for gestation at delivery and 300 controls who delivered appropriate for gestational age neonates. The median multiple of the median (MoM) serum adiponectin in the two outcome groups was compared and the bivariate Gaussian distributions were simulated in a screened population of 33 344 pregnancies to estimate the performance of screening for macrosomia by a combination of maternal characteristics and obstetric history with serum adiponectin. RESULTS: In the macrosomic group the median serum adiponectin [0.82, interquartile range (IQR): 0.56-1.02 MoM] was significantly lower than in the non-macrosomic controls (1.02, IQR: 0.70-1.29 MoM; p = 0.001). The estimated detection rate of macrosomia, at fixed false positive rate of 10%, from maternal characteristics and obstetric history was 34.6% and this increased to 38.2% with the addition of serum adiponectin. CONCLUSION: Maternal serum adiponectin at 11 to 13 weeks is a useful biomarker for early prediction of macrosomia.
Asunto(s)
Adiponectina/sangre , Macrosomía Fetal/diagnóstico , Primer Trimestre del Embarazo/sangre , Diagnóstico Prenatal/métodos , Adulto , Biomarcadores/sangre , Peso al Nacer , Peso Corporal , Estudios de Casos y Controles , Femenino , Macrosomía Fetal/sangre , Humanos , Recién Nacido , Paridad , Valor Predictivo de las Pruebas , Embarazo , Resultado del Embarazo , Estudios Prospectivos , Curva ROCRESUMEN
OBJECTIVE: To investigate whether maternal serum levels of adiponectin in the first trimester are altered in pregnancies that subsequently deliver small for gestational age (SGA) neonates. METHODS: Maternal serum adiponectin and pregnancy-associated plasma protein A (PAPP-A) were measured at 11-13 weeks' gestation in 50 singleton normotensive pregnancies that delivered SGA neonates and 300 non-SGA controls. The median adiponectin and PAPP-A levels in the SGA and non-SGA groups, expressed as multiple of the unaffected median (MoM), were compared. RESULTS: The distribution of serum adiponectin was made gaussian by square root (sqrt) transformation. Regression analysis in the non-SGA group demonstrated that for sqrt adiponectin a significant independent contribution was provided by maternal age, weight, smoking status, African and South-Asian racial origin. Each value in the SGA and non-SGA group was then converted into a multiple of the non-SGA median (MoM) after adjustment for maternal characteristics. In the SGA group, compared to the non-SGA controls, median maternal serum PAPP-A was decreased (0.79, interquartile range [IQR] 0.54-1.06 MoM vs. 1.00, IQR 0.71-1.39 MoM) but adiponectin MoM was not significantly different (0.89, IQR 0.65-1.31 MoM vs. 1.02, IQR 0.70-1.29 MoM). CONCLUSION: Maternal serum adiponectin is not a useful biochemical marker for early prediction of SGA.
Asunto(s)
Adiponectina/sangre , Edad Gestacional , Recién Nacido Pequeño para la Edad Gestacional/sangre , Adulto , Femenino , Humanos , Recién Nacido , Embarazo , Proteína Plasmática A Asociada al Embarazo/análisis , Análisis de RegresiónRESUMEN
OBJECTIVE: To develop a model for the prediction of gestational diabetes mellitus (GDM) from maternal characteristics and biochemical markers at 11 to 13 weeks' gestation. METHODS: A prospective screening study on early prediction of pregnancy complications (n = 11, 464), including 297 (2.6%) cases of GDM was used to create the predictive model of GDM based on maternal characteristics. Maternal serum concentrations of adiponectin, follistatin-like-3 (FSTL3) and sex hormone-binding globulin (SHBG) were measured in a case-control study of 80 women who developed GDM and 300 controls. RESULTS: In the screening study, maternal age, body mass index, racial origin, previous history of GDM and macrosomic neonate were significant independent predictors of future GDM. In the GDM group, compared to controls, the median multiple of the normal median adiponectin (0.66; IQR: 0.5-0.9 vs 1.02; IQR: 0.7-1.29) and SHBG (0.81; IQR: 0.6-1.04 vs 1.02; IQR: 0.8-1.2) was lower (p < 0.05), but FSTL3 was not significantly different. In screening for GDM by maternal characteristics, the detection rate was 61.6% at a false-positive rate of 20% and the detection increased to 74.1% by the addition of adiponectin and SHBG. CONCLUSION: First-trimester screening for GDM can be provided by a combination of maternal characteristics and biomarkers.