A second look at intrapartum fetal surveillance and future directions.

Intrapartum fetal surveillance aims to predict significant fetal hypoxia and institute timely intervention to avoid fetal injury, and do so without unnecessary operative delivery of fetuses at no risk of intrapartum hypoxia. However, the configuration and application of current clinical guidelines inadvertently undermine these aims because of persistent failure to incorporate increased understanding of fetal cardiovascular physiology and adaptations to oxygen deprivation, advances in signal acquisition/processing, and related technologies. Consequently, the field on intrapartum fetal surveillance is stuck in rudimentary counts of the fetal R-R intervals and visual assessment of very common, but nonspecific fetal heart decelerations and fetal heart rate variability. The present authors argue that the time has come to move away from classifications of static morphological appearances of FHR decelerations, which do not assist the thinking clinician in understanding how the fetus defends itself and compensates for intrapartum hypoxic ischaemic insults or the patterns that suggest progressive loss of compensation. We also reappraise some of the controversial aspects of intrapartum fetal surveillance in modern obstetric practice, the current state of flux in training and certification, and contemplate the future of the field particularly in the context of the emerging role of artificial intelligence.

Outcomes of the first 50 patients with abnormally invasive placenta managed using the "Triple P Procedure" conservative surgical approach.

OBJECTIVE: To determine maternal outcomes for women with abnormally invasive placenta (AIP) managed using the Triple P Procedure and establish its safety as a conservative surgical management option. METHODS: A retrospective study of the outcomes of the first 50 patients who underwent the Triple P Procedure for AIP from September 2010 to May 2017 at St George's Maternity Unit. Maternity case notes and the database were reviewed to determine the volume of bleeding, procedure-related complications, hysterectomy rate, and postoperative hospitalization. RESULTS: Mean operative blood loss was 2318 mL (range, 400-7300 mL and the incidence of bladder and ureteric injuries was 2% (n=1) and 0%, respectively. Median length of hospital stay was 4 days (range, 2-8 days). Three women (6.0%) developed arterial thrombosis without any long-term complications and none of the patients required peripartum hysterectomy. CONCLUSION: The Triple P Procedure should be considered as a conservative, less risky alternative to a peripartum hysterectomy during counselling prior to surgery for women with AIP.

A Randomized Trial of Prophylactic Antibiotics for Miscarriage Surgery.

BACKGROUND: Surgical intervention is needed in some cases of spontaneous abortion to remove retained products of conception. Antibiotic prophylaxis may reduce the risk of pelvic infection, which is an important complication of this surgery, particularly in low-resource countries. METHODS: We conducted a double-blind, placebo-controlled, randomized trial investigating whether antibiotic prophylaxis before surgery to complete a spontaneous abortion would reduce pelvic infection among women and adolescents in low-resource countries. We randomly assigned patients to a single preoperative dose of 400 mg of oral doxycycline and 400 mg of oral metronidazole or identical placebos. The primary outcome was pelvic infection within 14 days after surgery. Pelvic infection was defined by the presence of two or more of four clinical features (purulent vaginal discharge, pyrexia, uterine tenderness, and leukocytosis) or by the presence of one of these features and the clinically identified need to administer antibiotics. The definition of pelvic infection was changed before the unblinding of the data; the original strict definition was two or more of the clinical features, without reference to the administration of antibiotics. RESULTS: We enrolled 3412 patients in Malawi, Pakistan, Tanzania, and Uganda. A total of 1705 patients were assigned to receive antibiotics and 1707 to receive placebo. The risk of pelvic infection was 4.1% (68 of 1676 pregnancies) in the antibiotics group and 5.3% (90 of 1684 pregnancies) in the placebo group (risk ratio, 0.77; 95% confidence interval [CI], 0.56 to 1.04; P = 0.09). Pelvic infection according to original strict criteria was diagnosed in 1.5% (26 of 1700 pregnancies) and 2.6% (44 of 1704 pregnancies), respectively (risk ratio, 0.60; 95% CI, 0.37 to 0.96). There were no significant between-group differences in adverse events. CONCLUSIONS: Antibiotic prophylaxis before miscarriage surgery did not result in a significantly lower risk of pelvic infection, as defined by pragmatic broad criteria, than placebo. (Funded by the Medical Research Council and others; AIMS Current Controlled Trials number, ISRCTN97143849.).

Tranexamic acid for the prevention of postpartum bleeding in women with anaemia: study protocol for an international, randomised, double-blind, placebo-controlled trial.

BACKGROUND: Postpartum haemorrhage (PPH) is responsible for about 100,000 maternal deaths every year, most of which occur in low- and middle-income countries. Tranexamic acid (TXA) reduces bleeding by inhibiting the enzymatic breakdown of fibrin blood clots. TXA decreases blood loss in surgery and reduces death due to bleeding after trauma. When given within 3 h of birth, TXA reduces deaths due to bleeding in women with PPH. However, for many women, treatment of PPH is too late to prevent death. Over one third of pregnant women in the world are anaemic and many are severely anaemic. These women have an increased risk of PPH and suffer more severe outcomes if PPH occurs. There is an urgent need to identify a safe and effective way to reduce postpartum bleeding in anaemic women. METHODS/DESIGN: The WOMAN-2 trial is an international, multicentre, randomised, double-blind, placebo-controlled trial to quantify the effects of TXA on postpartum bleeding in women with moderate or severe anaemia. Ten thousand women with moderate or severe anaemia who have given birth vaginally will be randomised to receive 1 g of TXA or matching placebo by intravenous injection immediately (within 15 min) after the umbilical cord is cut or clamped. The primary outcome is the proportion of women with a clinical diagnosis of primary PPH. The cause of PPH will be described. Data on maternal health and wellbeing, maternal blood loss and its consequences, and other health outcomes will be collected as secondary outcomes. The main analyses will be on an 'intention-to-treat' basis, irrespective of whether the allocated treatment was received. Results will be presented as appropriate effect estimates with a measure of precision (95% confidence intervals). Subgroup analyses will be based on the severity of anaemia (moderate versus severe) and type of labour (induced or augmented versus spontaneous). A study with 10,000 patients will have over 90% power to detect a 25% relative reduction from 10 to 7.5% in PPH. The trial will be conducted in hospitals in Africa and Asia. DISCUSSION: The WOMAN-2 trial should provide reliable evidence for the effects of TXA for preventing postpartum bleeding in women with anaemia. TRIAL REGISTRATION: ISRCTN, ISRCTN62396133 . Registered on 7 December 2017; ClincalTrials.gov, ID: NCT03475342 . Registered on 23 March 2018.

Reproductive outcomes after assisted conception.

The last three decades have witnessed a dramatic increase in the use of assisted reproductive technology (ART) so that now, in developed countries, 1.7% to 4.0% of all children are born after ART. Although absolute risks appear small, data from prospective and retrospective studies indicate increased risks of adverse maternal and perinatal outcomes after ART as compared with spontaneous conception. Recent studies suggest that underlying maternal factors and subfertility play an important role in some of these outcomes rather than the ART procedure itself. A significant risk of assisted conception is multiple pregnancies, but even singleton pregnancies achieved by ART are at a higher risk of hypertensive disease, diabetes, prematurity, low birth weight, and perinatal mortality even after adjusting for confounders. Couples undergoing ART procedures should be counseled in advance regarding increased risks of pregnancy complications and higher rates of obstetric interventions. Although conflicting data exist, studies of children born from ART suggest increased rates of congenital malformations, imprinting disorders (Beckwith-Wiedemann syndrome and Angelman syndrome), and marginally increased risk of cancer. However, the current evidence is inadequate, and prospective long-term studies are needed to eliminate the effect of confounders and draw definite conclusions about the long-term outcomes after ART. The absolute risk of imprinting disorders remains small, and routine screening is not recommended at present. The long-term outcomes after ART are difficult to evaluate because of the variability in ART methods and data reporting, and there is a need for standardized methodology for follow-up after ART.

The Triple-P procedure as a conservative surgical alternative to peripartum hysterectomy for placenta percreta.

The reported maternal mortality for morbidly adherent placenta ranges from 7% to 10% worldwide. Current treatment modalities for this potentially life-threatening condition include radical approaches such as elective peripartum hysterectomy with or without bowel/bladder resection or ureteric re-implantation (for placenta percreta infiltrating these organs), and conservative measures such as compression sutures with balloon tamponade and the placenta remaining in situ. However, both conservative and radical measures are associated with significant maternal morbidity and mortality. The present article describes the Triple-P procedure-which involves perioperative placental localization and delivery of the fetus via transverse uterine incision above the upper border of the placenta; pelvic devascularization; and placental non-separation with myometrial excision and reconstruction of the uterine wall-as a safe and effective alternative to conservative management or peripartum hysterectomy.

Folic acid in obstetric practice: a review.

UNLABELLED: Folic acid is one of the B complex vitamins and is now recognized as a major component of the periconceptional care of women in the reproductive age group. Deficiency of folic acid can lead to neural tube defects in the fetus and megaloblastic anemia in the mother. Due to its lower bioavailability from natural foods, many countries have adopted mandatory folic acid food fortification programs. Although these programs have been a public health triumph in reducing the burden of neural tube defects, there have been growing concerns about the role played by folic acid supplementation in the rising colon cancer rates over the past decade. The majority of the evidence available to date is reassuring, and until further long-term population as well as laboratory studies are completed, folic acid will continue to play a vital role in early pregnancy care. It is important for healthcare professionals to be aware of the recent evidence that has accumulated, suggesting higher folic acid requirements in certain groups of women and offer correct advice on the use of folic acid supplements. This review looks at some of the existing evidence on folic acid supplementation and summarizes the recommendations on the use of folic acid supplements by obstetricians, family physicians, and others providing prenatal care. TARGET AUDIENCE: Obstetricians and Gynecologists, Family physicians. LEARNING OBJECTIVES: After completing this CME activity, physicians should be better able to evaluate the need for folic acid supplementation in various patient groups to lower the risk of neural tube defects due to folate deficiency; recommend common, natural and fortified food sources rich in folic acid; and distinguish the effects of folate deficiency in the mother and fetus.

Are all brachial plexus injuries caused by shoulder dystocia?

UNLABELLED: Obstetric brachial plexus palsy (OBPP), is an injury of the brachial plexus at childbirth affecting the nerve roots of C5-6 (Erb-Duchenne palsy-nearly 80% of cases) or less frequently the C8-T1 nerve roots (Klumpke palsy). OBPP often has medicolegal implications. In the United Kingdom and the Republic of Ireland the incidence is 0.42, in the United States 1.5, and in other western countries 1 to 3 per 1000 live births. Most infants with OBPP have no known risk factors. Shoulder dystocia increases the risk for OBPP 100-fold. The reported incidence of OBPP after shoulder dystocia varies widely from 4% to 40%. Other risk factors include birth weight >4 kg, maternal diabetes mellitus, obesity or excessive weight gain, prolonged pregnancy, prolonged second stage of labor, persistent fetal malposition, operative delivery, and breech extraction of a small baby. OBPP after caesarean section accounts for 1% to 4% of cases. Historically, OBPPs have been considered to result from excessive lateral traction and forceful deviation of the fetal head from the axial plane of the fetal body, usually in association with shoulder dystocia, which increases the necessary applied peak force and time to deliver the fetal shoulders. Direct compression of the fetal shoulder on the symphysis pubis may also cause injury. However a significant proportion of OBPPs occurs in utero, as according to some studies more than half of the cases are not associated with shoulder dystocia. Possible mechanisms of intrauterine injury include the endogenous propulsive forces of labor, intrauterine maladaptation, or failure of the shoulders to rotate, and impaction of the posterior shoulder behind the sacral promontory. Uterine anomalies, such as fibroids, an intrauterine septum, or a bicornuate uterus may also result in OBPP. It is not possible to reliably predict which fetuses will experience OBPP. Future research should be directed in prospective evaluation of the mechanisms of injury, to enable obstetricians, midwives, and other health care professionals to identify modifiable risk factors, develop preventive strategies, and improve perinatal outcomes. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader will be able to summarize known risk factors for shoulder dystocia, describe the relationship between shoulder dystocia and obstetrics brachial plexus injuries, and describe three potentail explanantions for brachial plexus injuries other than lateral traction at delivery.

Surgical aspects of postpartum haemorrhage.

Postpartum haemorrhage (PPH) refers to excessive bleeding from the genital tract after birth. Failure of medical treatment to control bleeding would necessitate surgical measures to arrest haemorrhage, to save lives. Algorithms such as HAEMOSTASIS have been proposed as aids to the systematic and stepwise management of primary PPH. Clinicians need to be aware of various surgical techniques that could be employed to arrest haemorrhage, the appropriateness of a chosen surgical intervention to the specific clinical situation and the timing of instituting the intervention. Surgical measures to arrest PPH include repair of genital tract trauma, evacuation of retained products of conception, uterine balloon tamponade, exploratory laparotomy and uterine compression sutures, systematic pelvic devascularization, uterine artery embolization, subtotal and total abdominal hysterectomy. Consideration should also be given to the experience and the skill of the operator, as well as to the familiarity with the chosen surgical procedure.

Prevention of birth asphyxia: responding appropriately to cardiotocograph (CTG) traces.

Birth asphyxia is a broad term that refers to intrapartum asphyxia sufficient to cause neurological damage in some newborns and, rarely, intrapartum or neonatal death. Cerebral palsy and long-term neurological complications such as learning difficulties and motor impairments may be due to causes other than birth asphyxia. Several intrapartum events may cause asphyxia (i.e. hypoxia and metabolic acidosis) leading to the likelihood of neurological injury. The cardiotocograph (CTG) is a screening tool that is used to assess fetal well-being during labour and to identify the possibility of asphyxia. Abnormality of the CTG, sometimes severe enough to be described as a pathological trace, is commonly termed 'fetal distress', although many fetuses with such traces may not have hypoxia and metabolic acidosis. In current practice, the events are appropriately termed 'pathological CTG trace' or 'acidotic pH' rather than 'fetal distress'. Accurate interpretation of CTG is essential, and it is important to recognize a fetus that shows a pathological CTG in labour that may imply possible hypoxia and birth asphyxia. Considering the wider clinical picture in interpreting the CTG, and taking timely and appropriate action based on the findings, may help prevent birth asphyxia.

Progesterone enhances the tocolytic effect of ritodrine in isolated pregnant human myometrium.

OBJECTIVE: To evaluate the effect of natural progesterone on the relaxant effect of ritodrine on pregnant human oxytocin-induced myometrial contractility. STUDY DESIGN: Isometric tension recordings were performed under physiologic conditions on isolated myometrial strips taken from low-risk term pregnant women undergoing elective cesarean section. Cumulative effects of natural progesterone (10 (-11) to 10 (-5) mol/L) on oxytocin-induced myometrial contractility were evaluated. Contractile activity following ritodrine exposure was also investigated in myometrium pretreated with natural progesterone. RESULTS: Natural progesterone alone exerted a concentration-dependent relaxant effect on myometrial contractions. The concentration-response curve for ritodrine from natural progesterone pretreated myometrium was shifted to the left with a significant reduction ( P < .01) of 50% of the maximal response, contraction amplitude ( P < .05), and frequency ( P < .05). However, there was no significant difference in the mean maximal inhibition achieved ( P = .95). CONCLUSION: Natural progesterone increased the relaxant effect of ritodrine by reducing 50% of the maximal response, amplitude, and frequency of myometrial contraction, most likely through nongenomic actions. These results suggest that natural progesterone may be beneficial for preventing preterm birth in a low-risk population.

Pituitary and adrenal disorders complicating pregnancy.

PURPOSE OF REVIEW: Confidential enquiries of maternal deaths in the UK for 1997-1999 revealed that the number of indirect deaths from medical conditions exacerbated by pregnancy was greater than deaths from conditions directly caused by pregnancy. Indirect maternal deaths accounted for 36% of all deaths. Although neoplastic disorders of the pituitary and adrenal glands are very rare during pregnancy, they can be potentially fatal. The rarity of these disorders may pose difficulty in formulating an optimum plan of management. Biochemical tests that can be performed in the non-pregnant state may be of little value during pregnancy. The presence of a fetus may also influence the type and timing of intervention. RECENT FINDINGS: A few case reports have been reported in the literature, but unfortunately no large series to develop guidelines or protocols. However, endoscopic surgical procedures have recently been used in their management with good outcomes. New drugs such as octreotide and lanreotide are increasingly being used during pregnancy. Although too soon to assess the safety of these new treatments, results so far have been very encouraging. SUMMARY: Awareness of these potentially fatal neoplastic disorders of the pituitary and adrenal glands, coupled with early diagnosis and appropriate treatment, may help improve maternal and fetal outcomes. Advances in imaging techniques and endoscopic procedures are also likely to change clinical practice. Various new treatment options are being reported in the literature, but they are not supported by randomized, controlled trials. Further research is needed to determine their safety and efficacy during pregnancy.

Infrared spectral features of exfoliated cervical cells, cervical adenocarcinoma tissue, and an adenocarcinoma cell line (SiSo).

OBJECTIVE: The objective of the present study is to evaluate and compare the infrared spectral features of normal and malignant exfoliated cervical cells, cells from malignant tissue, and the SiSo cell line. METHODS: Infrared spectra of cervical adenocarcinoma (CA) tissue, normal and malignant exfoliated cervical cells, and a uterine cervical adenocarcinoma cell line (SiSo) were obtained. Spectral qualities in terms of band intensity ratio and band position, which reflect configurational changes in the functional groups of the above samples, were measured. RESULTS: Spectral bands of CA tissue, exfoliated cells from CA, and the cell line were similar but markedly different from that of exfoliated normal cervical cells. Significant changes in bands at 1025 cm(-1) (glycogen), 1080 cm(-1) (glycogen and nucleic acids), 1155 cm(-1) (C-OH groups of serine, threonine, and tyrosine of cell proteins, and C-O groups of carbohydrates), 1240 cm(-1) (PO(2) groups of nucleic acids), 1400 cm(-1) (methyl group of lipids and proteins), and 1450 cm(-1) (methylene group of lipids and proteins) were noted in the CA tissue, exfoliated CA cells, and adenocarcinoma cell line compared with exfoliated normal cells. Marked shifts in band positions from 1080 to 1086 cm(-1), 1153 to 1160 cm(-1), and 935 to 970 cm(-1) in CA tissue, exfoliated CA cells, and the adenocarcinoma cell line were noted. CONCLUSION: Spectral bands of the adenocarcinoma cell line matched very well with those of cervical CA tissue and exfoliated CA cells in terms of position. In contrast, spectral bands of the SiSo cell line differed greatly from those of normal exfoliated cells.