Risk for adverse maternal outcomes among women with chronic hypertension.

OBJECTIVE: To determine whether longitudinal health data accounts for end-organ injury or death in the setting of chronic hypertension. DESIGN: Cohort of 64 799 deliveries to 61 854 women. SETTING: US claims data for the preiod 2008-2019. POPULATION: Women with a delivery hospitalisation and chronic hypertension. METHODS: Risk for a composite of acute end-organ injury or death during the delivery hospitalisation and 30 days postpartum was analysed. Adjusted logistic regression models were derived with discrimination for each model estimated by the C-statistic. Poisson regression was used to estimate adjusted risk ratios. Starting with models using data from pregnancy, further adjustment was performed accounting for healthcare use in the year prior to pregnancy, including hospitalisations, emergency department encounters, prescription medications and pre-pregnancy diagnoses. MAIN OUTCOME MEASURES: Acute end-organ injury or death. RESULTS: The composite outcome occurred among 5.7% of 64 799 deliveries. For patients with commercial insurance, filling non-hypertensive medications from ≥11 different classes, compared with none (adjusted risk ratio, aRR 4.07, 95% CI 2.86-5.79), three or more hospitalisations before pregnancy, compared with none (aRR 4.75, 95% CI 3.46-6.52), and chronic kidney disease diagnosed in the year before pregnancy (aRR 2.35, 95% CI 1.88, 2.94) were associated with increased risk. For pregnancies covered by commercial insurance, the C-statistic increased from 0.615 (95% CI 0.599-0.630) in the model with pregnancy data only to 0.796 (95% CI 0.783-0.808) for the model additionally including healthcare use in the year before pregnancy. Findings with Medicaid were similar. CONCLUSIONS: Prepregnancy care use predicted adverse maternal outcomes. These data may be important in risk stratification.

Reference intervals for reticulocyte parameters (reticulocyte haemoglobin equivalent and immature reticulocyte fraction) in first-trimester pregnancy.

Reticulocyte parameters including reticulocyte haemoglobin equivalent (Ret-He) and immature reticulocyte fraction (IRF) are newly recognised hematological parameters that are being used for diagnosis and follow-up of anaemic patients. Reference intervals of these parameters have been established in different populations, however, the data relating to pregnancy are still lacking. One hundred and fifty-five first-trimester pregnant females were screened and the reference interval was calculated after selecting the patient with fixed criteria. R statistical software was used for statistical calculations. We tried to establish a reference interval of Ret-He content and IRF in first-trimester pregnancy in our study.IMPACT STATEMENTWhat is already known on this subject? Ret-He and IRF have been established as the marker of iron deficiency and iron-deficiency anaemia in different age groups and as a marker of response to iron therapy. However, literature is scarce regarding the reference intervals of these parameters, especially in pregnancy.What do the results of this study add? This study establishes the reference interval of newer reticulocyte parameters in first-trimester pregnancy which is not yet established in the literature. Establishing a reference interval is required for any laboratory parameters to be used in the clinical context.What are the implications of these findings for clinical practice and further research? The results of this study may help in making a clinical decision regarding iron deficiency in early pregnancy which is one of the common clinical problems in pregnancy. This study also serves as a baseline study for further studies of reference intervals for newer reticulocyte parameters in pregnancy. A similar study with a larger study population and follow-up with iron therapy may establish these parameters as one of the important markers of iron deficiency in pregnancy and help institute iron therapy on case-to-case basis.

Open issues in management of carbon monoxide poisoning in pregnancy: practical suggestions.

Carbon monoxide (CO) poisoning during pregnancy may cause deleterious effects to the fetus. Hyperbaric oxygen therapy (HBO) in pregnancy is proven to be safe and it is considered to be beneficial, reducing the severity of the fetal injuries. However, a number of issues are still to be discussed, among them the question of the carboxyhemoglobin (COHb) levels that trigger HBO therapy in pregnant CO poisoned patients. In this letter we report some practical suggestions for organizations wishing to develop their own protocols.

Comparison of obstetric and neonatal outcomes between Syrian adolescent refugees and local Turkish adolescent citizens.

The provision of antenatal care in adolescents in refugee populations presents particular difficulties because of conflict, nutritional deficiencies, language barriers and lack of access to health care facilities. Due to the absence of prenatal care, associated medical complications can occur. A total of 525 adolescent women who gave birth to singletons agreed to participate in this study. Data about maternal demographic and obstetric characteristics, as well as neonatal outcomes were analysed. In conclusion, adolescent pregnancy continues to be an important social problem due to health support needs. However, the results of our present study are important in terms of showing that perinatal care is quietly improving in Turkey.Impact StatementWhat is already known on this subject? Adolescent pregnancies are at much higher risk than adult pregnancies in terms of complications. These complications include preterm delivery, intrauterine growth retardation, maternal morbidity and mortality, neonatal morbidity and mortality. According to various beliefs and traditions, marriages in early ages are observed in some societies and as a result, adolescents become pregnant. Additionally, the present study includes early adolescent aged pregnancies as 14,15 and 16. As far as we search in the literature, there is no reported about early adolescent pregnancies.What do the results of this study add? Often, such pregnancies occur more frequently in societies with low socioeconomic levels. For this reason routine pregnancy screening, support during pregnancy, prenatal care is not adequately provided. Some of the complications develop on them. Primarily, the adolescent pregnancies should be gotten under control, if not, some complications can be prevented by routine pregnancy follow-up and adequate provision of prenatal care and support.What are the implications of these findings for clinical practice and/or further research? As a guide on clinical practices and further studies; an effective method of contraception should be applied to sexually active women at early maternal age. If not, pregnancies should be kept under close follow-up and with adequate support to avoid complications.

Socio-behavioural determinants of maternal near miss: a prospective case control study from a tertiary care centre of India.

Near miss occurs in far greater numbers than maternal deaths and allows a more robust quantification on risk factors and determinants of life-threatening complications. A 'Three delay model' has been proposed in identification of causes of near miss and maternal deaths. There may be delay in seeking and obtaining health care: delay in recognising danger signs and deciding to reach source of care, delay in reaching appropriate source of care and delay in obtaining appropriate and adequate treatments. We compared various delays between near miss cases (n = 100) and controls (n = 200). Women who fulfilled criteria of near miss were taken as cases. Women who had obstetrical complications like near miss but were managed successfully and did not reach near miss state were labelled as controls. Near miss were then compared with maternal death. For normally distributed measurable data, outcome was compared using Student's t-test, for non-normally distributed/ordinal data, outcome was compared using Mann-Whitney's test. For categorical/classified data, association with outcome was analysed using Chi-Square test/Fisher's exact test.Delay in all three levels was seen among the groups. Lack of knowledge, non-availability of decision maker, and concern of cost of transport were main contributors of these delays.Impact StatementWhat is already known on this subject? Nonavailability of healthcare and low socio-economic status strongly correlate with maternal morbidity and mortality.What do the results of this study add? Lack of knowledge, non-availability of the decision maker, and concern of cost of transport were the main contributors of delay in seeking medical care. Majority of the cases of near miss were attributed to poor utilisation of health resources, ignorance and lack of emergency obstetric care at the primary level.What are the implications of these findings for clinical practice and/or further research? Patient and attendant education to ensure follow-up visits, recognise danger signs and report without undue delay, compliance to dietary modifications, medications given needs to be addressed at every visit to reduce the impact of socio-behavioural determinants on maternal near miss and mortality which are preventable in majority of cases.

A review of modern and Vedic practices on use of umbilical cord.

Stromal cells possess unique properties to regenerate themselves and cure various chronic illnesses. An easily available and ethical source for procurement of stromal cells is umbilical cord blood which is now being stored for future use. Vedic texts also describe the cord blood as a source of life. However, Indian traditions seem to preserve one more alternative for storage and procurement of stromal cells. Traditionally, in many parts of India, the umbilical cord stump is dried and stored for future use. It is used as a medicine for some illness and to treat infertility. Since Indian traditions are an excerpt of Vedic science, it points towards the possible emergence of dried stump as an easy and cost-effective means for stromal cell procurement and storage. The present review compiles the literature available on these traditional practices and stresses upon the need of rigorous experimental and theoretical research in the area.

Maternal serum pregnancy-associated plasma protein-A concentration at 11-14 weeks of gestation and preeclampsia risk of women with common congenital anatomic uterine abnormalities.

To evaluate maternal serum pregnancy-associated plasma protein-A (PAPP-A) levels at 11-14 weeks of gestation and preeclampsia risk in women with common congenital anatomic uterine abnormalities (AUAs). First trimester screening markers were compared between 12 AUA pregnancies, 60 age matched controls and 12 cases of early preeclampsia. PAPP-A level and birth weight were significantly lower in AUA compared to control and early preeclampsia group (p<.001). Preeclampsia was absent in the AUAs pregnancies group. Birth weight were similar in AUA group when we compared AUA and control group regarding weeks of gestation at delivery and lower but not significantly, when we compared AUA and early preeclampsia group. Our findings suggest that AUA pregnancies are associated with low first trimester maternal serum PAPP-A concentrations not predictive of susceptibility to preeclampsia.Impact statementWhat is already known on this subject? During first trimester screening for preeclampsia based on maternal pregnancy-associated plasma protein A (PAPP-A) levels, various parameters are used, such as the somatometric characteristics of pregnant woman, single or multiple pregnancy, smoking status, family history, diabetes, hypertension and measurement of blood pressure and uterine artery Dopplers.What do the results of this study add? Our pioneer study revealed that there is drastic difference in PAPP-A concentration in women with common anatomic uterine abnormalities (AUAs), in comparison with their age matched control women with normal uterus.What are the implications of these findings for clinical practice and further research? Based on our results, uterine anatomical deviations, is another factor which must be taken in account for preeclampsia risk calculation and further clinical consultation and follow up in those pregnancies. Lower PAPP-A levels in AUA cases is a weak predictor of susceptibility to preeclampsia and could be associated to smaller placental size rather than poor placentation and in future research the calculation of the uterine cavity functional dimension may lead to a more accurate clinical assessment.

Risk of preterm delivery after medically indicated termination of pregnancy with induced vaginal delivery: a case-control study.

We investigated whether nonsurgical termination of pregnancy after 14 weeks of gestation increases the risk of preterm delivery in a subsequent pregnancy. We conducted a two-centre retrospective case-control study. Patients who underwent non-surgical termination of pregnancy after 14 weeks of gestation between 2012 and 2015 and who gave birth after 14 weeks of gestation to a live-born singleton infant were included. Control patients were those who gave birth after 37 weeks of gestation (the same month as a case patient) and had a second delivery of a singleton foetus after 14 weeks of gestation. The primary outcome was preterm delivery during the second pregnancy period. We included 151 cases and 302 controls and observed 13 (8.6%) preterm births during the second pregnancy in the case group versus 8 (2.6%) (odds ratio: 3.62; 95% confidence interval: 1.40-8.65, p < .001) in the control group. This result remained significant after multivariate analysis. Impact statementWhat is already known about this topic? Many studies have evaluated the association between first-trimester surgical or non-surgical termination of pregnancy and the risk of preterm birth in the subsequent pregnancy. However, no study has evaluated the association between second- or third-trimester non-surgical termination of pregnancy due to foetal disease and the risk of preterm birth in the subsequent pregnancy. A small number of studies have included a small proportion of patients who previously underwent non-surgical termination of pregnancy after 14 weeks of gestation and later experienced first-trimester termination during their second pregnancy. These studies focussed on the impact of the interpregnancy interval or pharmacological induction of labour on the risk of preterm delivery in the subsequent pregnancy.What did the results of this study add? This is the first study to specifically evaluate the association between second- and third-trimester non-surgical terminations of pregnancy and the risk of preterm birth in the subsequent pregnancy. When compared with term birth, nonsurgical termination of pregnancy was associated with the risk of spontaneous preterm birth and hospitalisation in the neonatal intensive care unit in the subsequent pregnancy.What are the implications of these findings for clinical practice and further research? Further studies are required to confirm our results, but information delivered to patients with a late termination of pregnancy and during their pregnancy follow-up for the subsequent pregnancy could be modified to provide this information.

Maternal risk of hypertension 7-15 years after pregnancy: clues from the placenta.

OBJECTIVE: To assess whether pre-eclampsia (PE)-related placental/extraplacental membrane findings are linked to moderately elevated blood pressure (BP) in pregnancy and later-life hypertension. DESIGN: Prospective cohort. SETTING: 52 prenatal clinics, 5 Michigan communities. SAMPLE: The POUCH Study recruited women at 16-27 weeks' gestation (1998-2004) and studied a sub-cohort in depth. This sample (n = 490) includes sub-cohort women with detailed placental assessments and cardiovascular health evaluations 7-15 years later in the POUCHmoms follow-up study. METHODS: PE-related placental/extraplacental membrane findings (i.e. mural hyperplasia, unaltered/abnormal vessels or atherosis in decidua; infarcts) were evaluated in relation to pregnancy BP and odds of Stage 2 hypertension at follow up using weighted polytomous regression. Follow-up hypertension odds also were compared in three pregnancy BP groups: normotensives (referent) and moderately elevated BP with or without PE-related placental/extraplacental membrane findings. MAIN OUTCOME MEASURES: Stage 2 hypertension (SBP ≥140 mmHg and/or DBP ≥90 mmHg, or using antihypertensive medications) at follow up. RESULTS: After excluding women with pregnancy hypertension (i.e. chronic, PE, gestational), mural hyperplasia and unaltered/abnormal decidual vessels were each associated with Stage 2 hypertension at follow up: adjusted odds ratio (aOR) = 2.7, 95% CI 1.1-6.6, and aOR = 1.7 (95% CI 0.8-3.4), respectively. Women with moderately elevated BP in pregnancy and evidence of mural hyperplasia or unaltered/abnormal decidual vessels had greater odds of Stage 2 hypertension at follow up: aOR = 4.5 (95% CI 1.6-12.5 and aOR = 2.6, 95% CI 1.1-5.9, respectively. CONCLUSIONS: PE-related placental/extraplacental membrane findings help risk-stratify women with moderately elevated BP in pregnancy for later development of hypertension. TWEETABLE ABSTRACT: Placental findings associated with mother's risk of later-life hypertension.

Rationalisation of the caesarean section rate in a tertiary referral hospital using the Robson classification.

The aim of this study was to implement the Robson Ten Groups Classification System (RTGCS) to identify the main contributors to the caesarean section (CS) rate and to evaluate whether the introduction of a plan of obstetrical interventions reduced this rate. An observational retrospective cross-sectional study was conducted during two time periods at Alicante University General Hospital. In the pre-implementation period (2009-2012), RTGCS was applied to identify the main groups contributing to the overall CS rate. In the post-implementation period (2013-2017), RTGCS was applied again to identify changing trends in CS rates. In all, 11,034 deliveries during the pre-intervention period and 11,453 during the post-intervention period were analysed. The overall CS rate was 23.9% and 20.9%, respectively. There were no changes in perinatal outcomes. In the post-intervention period, there was a significant decrease of the CS rate in the groups of targeted interventions 1, 2, 3, 4, 5, and 8B.Impact statementWhat is already known on this subject? High CS rates are becoming a public health problem because of risks, costs, excessive medicalisation, and abuse of resources. RTGCS provides a framework for auditing and analysing CS rates.What do the results of this study add? RTGCS can identify the groups that have the greatest impact on the CS rate and monitor changes in it consequent to policy changes.What are the implications of these findings for clinical practice? The introduction of a strategic plan with evidence-based clinical interventions may have a greater effect on the CS rate than other features justifying the increase in the incidence of CS.

Socioeconomic differences in caesarean section - are they explained by medical need? An analysis of patient record data of a large Kenyan hospital.

BACKGROUND: Caesarean section (C-section) rates are often low among the poor and very high among the better-off in low- and middle-income countries. We examined to what extent these differences are explained by medical need in an African context. METHODS: We analyzed electronic records of 12,209 women who gave birth in a teaching hospital in Kenya in 2014. C-section rates were calculated by socioeconomic position (SEP), using maternal occupation (professional, small business, housewife, student) as indicator. We assessed if women had documented clinical indications according to hospital guidelines and if socioeconomic differences in C-section rates were explained by indication. RESULTS: Indication for C-section according to hospital guidelines was more prevalent among professionals than housewives (16% vs. 9% of all births). The C-section rate was also higher among professionals than housewives (21.1% vs. 15.8% [OR 1.43; 95%CI 1.23-1.65]). This C-section rate difference was largely explained by indication (4.7 of the 5.3 percentage point difference between professionals and housewives concerned indicated C-sections, often with previous C-section as indication). Repeat C-sections were near-universal (99%). 43% of primary C-sections had no documented indication. Over-use was somewhat higher among professionals than housewives (C-section rate among women without indication: 6.6 and 5.5% respectively), which partly explained socioeconomic differences in primary C-section rate. CONCLUSIONS: Socioeconomic differences in C-section rates can be largely explained by unnecessary primary C-sections and higher supposed need due to previous C-section. Prevention of unnecessary primary C-sections and promoting safe trial of labor should be priorities in addressing C-section over-use and reducing inequalities. Unnecessary primary C-sections and ubiquitous repeat C-sections drive overall C-section rates and C-section inequalities.

Study of effects of mifepristone on full-term pregnancies.

The induction of labour is required for various indications in obstetrics. Various regimens and drugs are advocated for use in labour induction. Mifepristone is one such drug which has a definite role in first and second-trimester pregnancy terminations. However, its role in the third-trimester is still being reviewed. In the present study, the effect of mifepristone on cervical ripening was assessed and results interpreted.Impact statementWhat is already known on the subject? The role of mifepristone in termination of pregnancies at term is controversial. Some studies report onset of labour after giving mifepristone whereas others do not report any significant role.What do the results of the study add? Mifepristone has a role in improving Bishop score and can be used as a pre-induction cervical ripening agent before using other methods for labour induction. It does not report any adverse effects on the mother or foetus.What are the implications of these findings for clinical practice and/or further research? Mifepristone needs to be studied more in term pregnancies as induction of labour is increasingly required in today's scenario for various reasons. However, its role in improving the Bishop score as found in this study helps in decreasing dose of other labour inducing agents.

Chronic myeloid leukaemia in pregnancy: call for guidelines.

Although the incidence of chronic myeloid leukaemia (CML) in pregnancy is low, it is progressively rising. The management strategies for CML patients during pregnancy include tyrosine kinase inhibitors, interferon alpha, leukapheresis and hydroxyurea, each of which has their own deleterious effects on the mother and foetus. There are virtually no accepted guidelines on the therapeutic options for these patients. We report two cases of CML which were reported to us during pregnancy, on imatinib, with different ultimate pregnancy outcomes. We do believe that it is high time professional bodies frame guidelines for the management of these patients.

How well do women understand and remember information in labour versus in late pregnancy? A pilot randomised study.

Medical informed consent is the process by which a 'competent', non-coerced individual receives sufficient information including risks of a medical procedure and gives permission for it to occur. The capacity to give an informed consent might be impaired during labour. This study aimed to examine women's abilities to understand and remember during labour. Women were prospectively recruited at 36 weeks of gestation and randomised to undertake questionnaires which assessed their ability to understand and remember information. They were randomised to: (1) information given in labour only, written format (2) information in labour, verbal (3) information at 36 weeks plus labour, written (4) information at 36 weeks plus labour, verbal. Immediate comprehension and retention was assessed at 36 weeks, in labour, and 24-72 hours after birth. Forty-nine women completed the questionnaires regarding understanding and retention of information at 36 weeks, six intrapartum, and five postpartum (90% attrition). Women receiving information at 36 weeks and in labour versus in labour had a higher comprehension of pregnancy-related information, its retention, and total score. Women receiving information in late pregnancy and labour may comprehend and retain it better than women only receiving information during labour. Given small sample size, further research is needed to support these preliminary findings. Impact statement What is already known on this subject? The evidence regarding the capacity of labouring women to give informed consent is largely based on women's self-reported experiences or expert opinions and has mixed findings. Existing guidelines recommend that an informed consent should be given antenatally for both clinical practice and research. Studies show that obtaining an informed consent antenatally is neither feasible nor widely implemented. What do the results of this study add? A novel approach to providing empirical evidence regarding women's capacity to comprehend and retain information during labour. Our study confirms the difficulty with antenatal recruitment for intrapartum research. What are the implications of these findings for clinical practice and/further research? This raises ethical concerns regarding the current intrapartum research in which consent is largely sought at the time of the study. Emphasises the need to explore the question 'Do labouring women have the capacity to consent to research?' in order to ensure that women are protected during labour.

The impacted foetal head at caesarean section: incidence and techniques used in a single UK institution.

An impaction of the foetal head at caesarean section is a topical concern in modern obstetric practice. The management options for this problem are well described but the incidence or even definition of impaction, is unknown. The primary aim of this study was to ascertain the incidence of impacted foetal head at CS in labour. This prospective study used data from all women undergoing CS during a 12-month period in a single unit. Following completion of all CS, the surgeon completed a questionnaire covering: cervical dilation at time of CS; if the surgeon felt there was a difficulty in delivering the foetal head as an indicator of impaction, as well as the other techniques utilised. Of 440 EMCS in labour, 18% (n = 81) reported a difficulty delivering the head, which was most common at cervical dilation ≥8 cm (n = 124, 48%). A difficulty with the delivery of the foetal head was associated with 36% increased measured blood loss. Impact statement What is already known on this subject? Impaction of the foetal head at a caesarean section is a recognised complication of CS in late labour but there are no reliable data on the incidence of the problem. It is poorly defined and yet many techniques and devices have been described to overcome this problem, however, optimal management remains uncertain. What do the results of this study add? The primary aim of this study was to determine the incidence of the impacted foetal head during CS in labour as determined by whether the surgeon experienced difficulty with delivery of the head. We report that at least some difficulty in delivering the foetal head at CS is common, and most often encountered when cervical dilation is ≥8 cm. When additional manoeuvres were required, the 'push' technique was exclusively adopted with implications for training. A difficulty in delivering the foetal head was associated with a 36% increase in the measured maternal blood loss. What are the implications of these findings for clinical practice and/or further research? Further multi-centre investigation is required to ascertain incidence of this obstetric problem with predicting factors determined. This work will inform decisions about the optimal management.

Survey on knowledge, attitude, acceptance and related factors among pregnant women in Thailand regarding antenatal thalassaemia screening.

Thalassaemia is a common haematologic health condition in Southeast Asian countries (SEA) including Thailand. Reducing the birth of new thalassaemia cases is an effective method to control disease. The background level of knowledge and attitude of pregnant women on the disease influences their decision to perform antenatal screening. Unfortunately, the information about pregnant women's knowledge and attitude on antenatal thalassaemia screening in a developing country such as Thailand is lacking. We therefore conducted this cross-sectional study to examine patients' knowledge and to evaluate the factors which influence the patient's knowledge and attitude on antenatal thalassaemia screening. 1006 pregnant women who attended antenatal care at the Maha Chakri Sirindhorn Medical Center, Faculty of Medicine, Srinakharinwirot University, Ongkharak, Nakhon Nayok, Thailand were enrolled. We found that women's knowledge on antenatal thalassaemia screening is low. A maternal age of ≥35 years was associated with a higher level of knowledge. A higher level of education and multigravidity, a family history of thalassaemia and a positive level of attitude were found more likely to have higher scores for knowledge. A higher level of education and level of knowledge score were also more likely to have a positive attitude score, but multigravidity negatively affected the attitude score. Effective counselling should be monitored among women with a lower levels of education, those with no family history of thalassaemia, and in primigravidas. Lastly, a concurrent Down syndrome screening or foetal sex determination may be useful incentives to encourage the decision to undergo screening. Impact statement What is already known about this subject? Screening for the paternal and maternal thalassaemia carrier status is important for reducing the incidence of severely thalassaemia-affected children. Poorer education and receiving genetic counselling for the first time were the predictive factors for the low post-counselling knowledge in genetic counselling before second trimester genetic amniocentesis. What do the results of this study add? Pregnant women's knowledge of antenatal thalassaemia screening was low. We found that pregnant women aged ≥35 years had a higher level of knowledge. Women with a higher level of education, multigravidity, the presence of a family history of thalassaemia and a positive attitude were more likely to have higher scores for knowledge. A higher level of education and level of knowledge score were also more likely to have a positive attitude score but multigravidity negatively affected the attitude score. The encouraging factors, such as an adjunctive Down syndrome screening or foetal structural screening or foetal sex determination may be useful as the incentive tools. What are the implications of these finding for clinical practice and/or further research? The awareness of a possible incorrect understanding is important for the antenatal counselling in the developing countries. Intensive monitoring of effective counselling using a post-counselling test should be scheduled. The methods of effective counselling for antenatal thalassaemia in developing countries should be evaluated.

Teaching childbirth with high-fidelity simulation. Is it better observing the scenario during the briefing session?

The design of optimal courses for obstetric undergraduate teaching is a relevant question. This study evaluates two different designs of simulator-based learning activity on childbirth with regard to respect to the patient, obstetric manoeuvres, interpretation of cardiotocography tracings (CTG) and infection prevention. This randomised experimental study which differs in the content of their briefing sessions consisted of two groups of undergraduate students, who performed two simulator-based learning activities on childbirth. The first briefing session included the observations of a properly performed scenario according to Spanish clinical practice guidelines on care in normal childbirth by the teachers whereas the second group did not include the observations of a properly performed scenario, and the students observed it only after the simulation process. The group that observed a properly performed scenario after the simulation obtained worse grades during the simulation, but better grades during the debriefing and evaluation. Simulator use in childbirth may be more fruitful when the medical students observe correct performance at the completion of the scenario compared to that at the start of the scenario. Impact statement What is already known on this subject? There is a scarcity of literature about the design of optimal high-fidelity simulation training in childbirth. It is known that preparing simulator-based learning activities is a complex process. Simulator-based learning includes the following steps: briefing, simulation, debriefing and evaluation. The most important part of high-fidelity simulations is the debriefing. A good briefing and simulation are of high relevance in order to have a fruitful debriefing session. What do the results of this study add? Our study describes a full simulator-based learning activity on childbirth that can be reproduced in similar facilities. The findings of this study add that high-fidelity simulation training in childbirth is favoured by a short briefing session and an abrupt start to the scenario, rather than a long briefing session that includes direct instruction in the scenario. What are the implications of these findings for clinical practice and/or further research? The findings of this study reveal what to include in the briefing of simulator-based learning activities on childbirth. These findings have implications in medical teaching and in medical practice.

Ignorance is bliss: women's knowledge regarding age-related pregnancy risks.

Pregnancy risks rise with age and the average age of first time mothers is rising. This study aimed to assess women's actual knowledge and their perceived knowledge of pregnancy complications relating to advanced maternal age. A cross-sectional survey was administered to primiparous women measuring demographics, knowledge of age-related pregnancy risks, previous counselling and health literacy. Of the 218 women surveyed, the mean knowledge score was not significantly different for women <35 years of age compared to women ≥35 years of age (p = .09). Although there was no difference in knowledge between the two groups, women ≥35 years of age perceived themselves to be more knowledgeable than those under 35 (p < .01). The majority of women (67%) wanted further counselling on this topic and indicated a preference for their doctor to counsel them (76%). Women require counselling informing them of their increased risk of complications if they begin childbearing at older ages. Impact statement What is already known on this subject: The average age of first time mothers is rising worldwide. Pregnancy risks rise with age, especially in first time mothers. Previous studies have shown that knowledge of age-related pregnancy risks correlate with educational level and health literacy. What the results of this study add: This study supports those findings and also demonstrates that perceived knowledge does not correlate with measured knowledge of age-related pregnancy risks. Women ≥35 years of age (higher-risk women) are no more knowledgeable than their younger counterparts though they perceive themselves to be better informed. Greater education regarding these risks may allow women to mitigate some of these risks through lifestyle and diet alteration and will prepare women for what to expect if these risks and complications occur. The majority of women in this study seek pregnancy information on the internet, but desire further counselling from their doctors regarding age-related pregnancy risks. What the implications are of these findings for clinical practice and/or further research: Given these results, physicians must consider making greater efforts to counsel women about pregnancy risks in advanced maternal age and tailor these conversations to suit the educational level and health literacy of each individual patient.

Risk of recurrence of small-for-gestational-age foetus after first pregnancy.

The aim of this study was to assess the incidence of and to analyse factors related to the recurrence of small-for-gestational-age (SGA) neonates in the second pregnancy. A prospective observational study was conducted at a tertiary university hospital in Granada, Spain. A total of 7896 women who delivered their first and second singleton pregnancies at the hospital from 2003-2013 were included and evaluated all birth weights. Women whose first pregnancy was complicated by a SGA birth had a fivefold increased risk of recurrence (23.6% vs. 5.7%, p < .001). Multivariate analyses revealed that only SGA at first birth retained a statistically significant relationship, revealing that the other variables (maternal age, gestational age, interdelivery interval, maternal pre-pregnancy body mass index, occupation of the mother, smoking, hypertension, and diabetes mellitus) were confounders. Prevention of SGA in subsequent pregnancies by modification of established risk factors could be of limited utility based on the present results, supporting a genetic contribution to SGA recurrence. Impact statement The results support a genetic contribution on recurrence of SGA.

How much misoprostol is safe? - First reported case of second-trimester uterine rupture after a single low dose.

With the rising rate of caesarean births, the scenario of fetal demise occurring in a woman with previous caesarean births is becoming more prevalent. The optimal mode of management of intrauterine fetal demise in women with multiple caesarean births presents a challenge for the obstetricians due to absence of a definite protocol with good efficacy, safety and acceptability in these women. The risks of hysterotomy have to be balanced against the risk of uterine rupture with induction. Misoprostol is one of the most common drugs being used in mid-trimester miscarriage but with variable doses. The reports of uterine rupture with previous caesarean scar are rare and have occurred with different doses, making it difficult to counsel women regarding maternal risks. It is difficult to conduct a randomised control trial to address this issue due to limited number of patients and therefore no drug or dosage can be recommended with certainty. We present a unique and first case of second-trimester uterine rupture in a woman with three previous caesarean births and intrauterine fetal demise, after a single low dose of 25 µg vaginal misoprostol. This highlights the need for further research in context of misoprostol dosage in women with more than two previous caesarean births having second-trimester induction of labour.