Factors impacting on the decision of graduate entry medical school students to pursue a career in obstetrics and gynecology in Ireland.

BACKGROUND: Challenges in recruiting appropriately trained obstetricians and gynaecologists have been identified across the world. Given well documented staff shortages within obstetrics and gynaecology in Ireland, it is increasingly important to understand the factors which influence medical students to choose or reject a career in the speciality. The aim of this study was to ascertain the perceptions of final year graduate entry medical students of obstetrics and gynaecology, including the factors which may influence a student's decision to pursue in a career in the speciality. METHODS: Paper-based surveys of graduate entry medical students (n = 146) were conducted at the beginning and end of a six week rotation in obstetrics and gynaecology in Ireland. Responses to the surveys pre- and post-rotation were matched and changes in career choices, merits and demerits over time were analysed. All analysis was conducted using SPSS for Windows version 25. RESULTS: The responses of 72 students to both questionnaires could be matched (response rate of 49.3%). No male students expressed an interest in obstetrics, gynaecology or both as a first choice of career in the pre rotation survey. Obstetrics as a first choice of career increased from 6.9% pre rotation to 19.4% post rotation (p = 0.04) and this increase was seen in male and female students. Gynaecology as a first choice increased slightly from 1.4 to 4.2% (p = 0.50) and the dual speciality increased from 6.9 to 13.9% (p = 0.23). Students identified many merits of obstetrics pre-rotation with more than 60% identifying it as exciting, interesting fulfilling and challenging. However, incompatibility with family life was cited as a demerit by 72% of respondents and 68.1% identified fear of litigation as a demerit. Participants were less positive overall about the merits of a career in gynaecology with less than 40% viewing it as exciting, fulfilling, and varied. CONCLUSIONS: While respondents were positive about the merits of a career in obstetrics and gynecology, concerns remain about work-life balance, career opportunities, and the high-risk nature of the specialty. These concerns should be addressed by the profession and policy makers if they wish to attract sufficient numbers to address anticipated need in the coming years. Gender differences in speciality choice were also evident. If males are to be recruited into obstetrics and gynaecology, consideration should be given to the positive impact of internship.

Maternal obesity and degree of glucose intolerance on neonatal hypoglycaemia and birth weight: a retrospective observational cohort study in women with gestational diabetes mellitus.

Gestational diabetes mellitus (GDM) is an increasing problem worldwide. Postnatal hypoglycaemia and excess foetal growth are known important metabolic complications of neonates born to women with diabetes. This retrospective cohort study aims to determine the influence of obesity and glucose intolerance on neonatal hypoglycaemia and birth weight over the 90th percentile (LGA). Data were abstracted from 303 patient medical records from singleton pregnancies diagnosed with GDM. Data were recorded during routine hospital visits. Demographic data were acquired by facilitated questionnaires and anthropometrics measured at the first antenatal appointment. Blood biochemical indices were recorded. Plasma glucose area under the curve (PG-AUC) was calculated from OGTT results as an index of glucose intolerance. OGTT results of 303 pregnant women aged between 33.6 years (29.8-37.7) diagnosed with GDM were described. Neonates of mothers with a BMI of over 30 kg/m2 were more likely to experience neonatal hypoglycaemia (24 (9.2%) vs. 23 (8.8%), p = 0.016) with odds ratio for neonatal hypoglycaemia significantly higher at 2.105, 95% CI (1.108, 4.00), p = 0.023. ROC analysis showed poor strength of association (0.587 (95% CI, .487 to .687). Neonatal LGA was neither associated with or predicted by PG-AUC nor obesity; however, multiparous women were 2.8 (95% CI (1.14, 6.78), p = 0.024) times more likely to have a baby born LGA.Conclusion: Maternal obesity but not degree of glucose intolerance increased occurrence of neonatal hypoglycaemia. Multiparous women had greater risk of neonates born LGA.What is Known:•Excess foetal growth in utero has long-term metabolic implications which track into adulthood.•Neonatal hypoglycaemia is detrimental to newborns in the acute phase with potential long-term implications on the central nervous system.What is New:•Maternal obesity but not degree of glucose intolerance in a GDM cohort increased occurrence of neonatal hypoglycaemia.•Multiparous women diagnosed had greater risk of neonates born LGA.

Membrane sweeping for induction of labour.

BACKGROUND: Induction of labour involves stimulating uterine contractions artificially to promote the onset of labour. There are several pharmacological, surgical and mechanical methods used to induce labour. Membrane sweeping is a mechanical technique whereby a clinician inserts one or two fingers into the cervix and using a continuous circular sweeping motion detaches the inferior pole of the membranes from the lower uterine segment. This produces hormones that encourage effacement and dilatation potentially promoting labour. This review is an update to a review first published in 2005. OBJECTIVES: To assess the effects and safety of membrane sweeping for induction of labour in women at or near term (≥ 36 weeks' gestation). SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register (25 February 2019), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (25 February 2019), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised and quasi-randomised controlled trials comparing membrane sweeping used for third trimester cervical ripening or labour induction with placebo/no treatment or other methods listed on a predefined list of labour induction methods. Cluster-randomised trials were eligible, but none were identified. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, risk of bias and extracted data. Data were checked for accuracy. Disagreements were resolved by discussion, or by including a third review author. The certainty of the evidence was assessed using the GRADE approach. MAIN RESULTS: We included 44 studies (20 new to this update), reporting data for 6940 women and their infants. We used random-effects throughout. Overall, the risk of bias was assessed as low or unclear risk in most domains across studies. Evidence certainty, assessed using GRADE, was found to be generally low, mainly due to study design, inconsistency and imprecision. Six studies (n = 1284) compared membrane sweeping with more than one intervention and were thus included in more than one comparison. No trials reported on the outcomes uterine hyperstimulation with/without fetal heart rate (FHR) change, uterine rupture or neonatal encephalopathy. Forty studies (6548 participants) compared membrane sweeping with no treatment/sham Women randomised to membrane sweeping may be more likely to experience: · spontaneous onset of labour (average risk ratio (aRR) 1.21, 95% confidence interval (CI) 1.08 to 1.34, 17 studies, 3170 participants, low-certainty evidence). but less likely to experience: · induction (aRR 0.73, 95% CI 0.56 to 0.94, 16 studies, 3224 participants, low-certainty evidence); There may be little to no difference between groups for: · caesareans (aRR 0.94, 95% CI 0.85 to 1.04, 32 studies, 5499 participants, moderate-certainty evidence); · spontaneous vaginal birth (aRR 1.03, 95% CI 0.99 to 1.07, 26 studies, 4538 participants, moderate-certainty evidence); · maternal death or serious morbidity (aRR 0.83, 95% CI 0.57 to 1.20, 17 studies, 2749 participants, low-certainty evidence); · neonatal perinatal death or serious morbidity (aRR 0.83, 95% CI 0.59 to 1.17, 18 studies, 3696 participants, low-certainty evidence). Four studies reported data for 480 women comparing membrane sweeping with vaginal/intracervical prostaglandins There may be little to no difference between groups for the outcomes: · spontaneous onset of labour (aRR, 1.24, 95% CI 0.98 to 1.57, 3 studies, 339 participants, low-certainty evidence); · induction (aRR 0.90, 95% CI 0.56 to 1.45, 2 studies, 157 participants, low-certainty evidence); · caesarean (aRR 0.69, 95% CI 0.44 to 1.09, 3 studies, 339 participants, low-certainty evidence); · spontaneous vaginal birth (aRR 1.12, 95% CI 0.95 to 1.32, 2 studies, 252 participants, low-certainty evidence); · maternal death or serious morbidity (aRR 0.93, 95% CI 0.27 to 3.21, 1 study, 87 participants, low-certainty evidence); · neonatal perinatal death or serious morbidity (aRR 0.40, 95% CI 0.12 to 1.33, 2 studies, 269 participants, low-certainty evidence). One study, reported data for 104 women, comparing membrane sweeping with intravenous oxytocin +/- amniotomy There may be little to no difference between groups for: · spontaneous onset of labour (aRR 1.32, 95% CI 88 to 1.96, 1 study, 69 participants, low-certainty evidence); · induction (aRR 0.51, 95% CI 0.05 to 5.42, 1 study, 69 participants, low-certainty evidence); · caesarean (aRR 0.69, 95% CI 0.12 to 3.85, 1 study, 69 participants, low-certainty evidence); · maternal death or serious morbidity was reported on, but there were no events. Two studies providing data for 160 women compared membrane sweeping with vaginal/oral misoprostol There may be little to no difference between groups for: · caesareans (RR 0.82, 95% CI 0.31 to 2.17, 1 study, 96 participants, low-certainty evidence). One study providing data for 355 women which compared once weekly membrane sweep with twice-weekly membrane sweep and a sham procedure There may be little to no difference between groups for: · induction (RR 1.19, 95% CI 0.76 to 1.85, 1 study, 234 participants, low-certainty); · caesareans (RR 0.93, 95% CI 0.60 to 1.46, 1 study, 234 participants, low-certainty evidence); · spontaneous vaginal birth (RR 1.00, 95% CI 0.86 to 1.17, 1 study, 234 participants, moderate-certainty evidence); · maternal death or serious maternal morbidity (RR 0.78, 95% CI 0.30 to 2.02, 1 study, 234 participants, low-certainty evidence); · neonatal death or serious neonatal perinatal morbidity (RR 2.00, 95% CI 0.18 to 21.76, 1 study, 234 participants, low-certainty evidence); We found no studies that compared membrane sweeping with amniotomy only or mechanical methods. Three studies, providing data for 675 women, reported that women indicated favourably on their experience of membrane sweeping with one study reporting that 88% (n = 312) of women questioned in the postnatal period would choose membrane sweeping in the next pregnancy. Two studies reporting data for 290 women reported that membrane sweeping is more cost-effective than using prostaglandins, although more research should be undertaken in this area. AUTHORS' CONCLUSIONS: Membrane sweeping may be effective in achieving a spontaneous onset of labour, but the evidence for this was of low certainty. When compared to expectant management, it potentially reduces the incidence of formal induction of labour. Questions remain as to whether there is an optimal number of membrane sweeps and timings and gestation of these to facilitate induction of labour.

Antenatal Detection of Abnormal Placental Cord Insertion across Different Trimesters: A Prospective Cohort Study.

OBJECTIVES: This article prospectively examines the use of ultrasound for antenatal detection of abnormal placental cord insertion (PCI) and compares the antenatal classification with delivered placental classification. STUDY DESIGN: This prospective cohort study examined 277 singleton pregnancies in a tertiary center. Scans were performed between 10 and 14, 18 and 22, and 32 and 34 weeks where PCI site was identified and its shortest distance to margin measured. Standardized images of delivered placentas were taken and digitally measured. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of antenatal classification compared with delivered placental classification were calculated. RESULTS: Abnormal PCI (distance < 2 cm from margin) was confirmed in 30/277 (11%) placentas at delivery. Note that 102/277 (37%) of PCI sites were classified as abnormal in the first trimester (T1), 43/277 (16%) in the second trimester (T2), and 28/277 (10%) in the third trimester (T3). Sensitivity (73%) and specificity (91%) were highest at T2. The PPVs were low (22% in T1, 51% in T2, and 64% in T3) and the NPVs were high (96% in T1 and 97% in both T2 and T3) for all scans. CONCLUSION: Abnormal PCI can be detected antenatally with optimal agreement with postnatal classification in T2. However, the incidence is overestimated at early scans with low PPVs.

Inter and intra-reliability of ultrasonography for the measurement of abdominal subcutaneous & visceral adipose tissue thickness at 12 weeks gestation.

BACKGROUND: Excess abdominal adiposity cause metabolic disturbances, particularly in pregnancy. Methods of accurate measurement are limited in pregnancy due to risks associated with these procedures. This study outlines a non-invasive methodology for the measurement of adipose tissue in pregnancy and determines the intra- and inter-observer reliability of ultrasound (US) measurements of the two components of adipose tissue (subcutaneous (SAT) and visceral adipose tissue (VAT)) within a pregnant population. METHODS: Thirty pregnant women were recruited at the end of their first trimester, from routine antenatal clinic at the University Maternity Hospital Limerick, Ireland. Measurements of adipose tissue thickness were obtained using a GE Voluson E8 employing a 1-5 MHz curvilinear array transducer. Two observers, employing methodological rigour in US technique, measured thickness of adipose tissue three times, and segmented the US image systematically in order to define measurements of SAT and VAT using specifically pre-defined anatomical landmarks. RESULTS: Intra-observer and inter-observer precision was assessed using Coefficient of Variation (CV). Measurements of SAT and total adipose for both observers were < 5% CV and < 10% CV for VAT in measures by both observers. Inter-observer reliability was assessed by Limits of Agreement (LoA). LoA were determined to be - 0.45 to 0.46 cm for SAT and - 0.34 to 0.53 cm for VAT values. Systematic bias of SAT measurement was 0.01 cm and 0.10 cm for VAT. Inter-observer precision was also assessed by coefficient of variation (CV: SAT, 3.1%; VAT, 7.2%; Total adipose, 3.0%). CONCLUSION: Intra-observer precision was found to be acceptable for measures of SAT, VAT and total adipose according to anthropometric criterion, with higher precision reported in SAT values than in VAT. Inter-observer reliability assessed by Limits-Of-Agreement (LoA) confirm anthropometrically reliable to 0.5 cm. Systematic bias was minimal for both measures, falling within 95% confidence intervals. These results suggest that US can produce reliable, repeatable and accurate measures of SAT and VAT during pregnancy.

Role of 2-Dimensional Ultrasound Imaging in Placental and Umbilical Cord Morphometry: Literature and Pictorial Review.

Abnormalities of the placenta and umbilical cord have been associated with adverse pregnancy outcomes. Antenatal detection of placental and umbilical cord abnormalities using ultrasound (US) imaging is now gaining popularity with the advancements in obstetric US. This article reviews the use of 2-dimensional obstetric US as a tool to measure and assess placental and umbilical cord morphometry. It highlights the potential role of placental and umbilical cord morphometry as a valuable component of the screening tool for high risk pregnancies and identifies the need for further research to examine its feasibility.

The Impact of Aspirin on Ultrasound Markers of Uteroplacental Flow in Low-Risk Pregnancy: Secondary Analysis of a Multicenter RCT.

OBJECTIVE: This article evaluates the effect of low-dose aspirin on uterine artery (UtA) Doppler, placental volume, and vascularization flow indices in low-risk pregnancy. STUDY DESIGN: In this secondary analysis of the TEST randomized controlled trial, low-risk nulliparous women were originally randomized at 11 weeks to: (1) routine aspirin 75 mg; (2) no aspirin; and (3) aspirin based upon the preeclampsia Fetal Medicine Foundation screening test. UtA Doppler, three-dimensional (3D) placental volume, and vascularization flow indices were assessed prior to and 6 weeks postaspirin commencement. RESULTS: A total of 546 women were included (aspirin n = 192, no aspirin n = 354). Between first and second trimesters, aspirin use was not associated with a change in UtA Doppler, placental volume, or vascular flow indices. There was no significant difference in the change in UtA Doppler pulsatility index (PI) Z-scores or notching (PI Z-score -0.2 vs. -0.2, p = 0.17), nor was there a significant change in placental volume Z-score and vascular flow indices (volume Z-score change: 0.74 vs. 0.62, p = 0.34). CONCLUSION: Low-dose aspirin commenced at 11 weeks in low-risk women does not appear to improve uterine and placental perfusion or placental volume. Any perceived effect on uteroplacental vasculature is not reflected in changes in placental volume nor uteroplacental flow as assessed by two-dimensional and 3D ultrasound.

Prediction of cesarean delivery in the term nulliparous woman: results from the prospective, multicenter Genesis study.

BACKGROUND: In contemporary practice many nulliparous women require intervention during childbirth such as operative vaginal delivery or cesarean delivery (CD). Despite the knowledge that the increasing rate of CD is associated with increasing maternal age, obesity and larger infant birthweight, we lack a reliable method to predict the requirement for such potentially hazardous obstetric procedures during labor and delivery. This issue is important, as there are greater rates of morbidity and mortality associated with unplanned CD performed in labor compared with scheduled CDs. A prediction algorithm to identify women at risk of an unplanned CD could help reduced labor associated morbidity. OBJECTIVE: In this primary analysis of the Genesis study, our objective was to prospectively assess the use of prenatally determined, maternal and fetal, anthropomorphic, clinical, and ultrasound features to develop a predictive tool for unplanned CD in the term nulliparous woman, before the onset of labor. MATERIALS AND METHODS: The Genesis study recruited 2336 nulliparous women with a vertex presentation between 39+0 and 40+6 weeks' gestation in a prospective multicenter national study to examine predictors of CD. At recruitment, a detailed clinical evaluation and ultrasound assessment were performed. To reduce bias from knowledge of these data potentially influencing mode of delivery, women, midwives, and obstetricians were blinded to the ultrasound data. All hypothetical prenatal risk factors for unplanned CD were assessed as a composite. Multiple logistic regression analysis and mathematical modeling was used to develop a risk evaluation tool for CD in nulliparous women. Continuous predictors were standardized using z scores. RESULTS: From a total enrolled cohort of 2336 nulliparous participants, 491 (21%) had an unplanned CD. Five parameters were determined to be the best combined predictors of CD. These were advancing maternal age (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.09 to 1.34), shorter maternal height (OR, 1.72; 95% CI, 1.52 to 1.93), increasing body mass index (OR, 1.29; 95% CI, 1.17 to 1.43), larger fetal abdominal circumference (OR, 1.23; 95% CI, 1.1 to 1.38), and larger fetal head circumference (OR, 1.27; 95% CI, 1.14 to 1.42). A nomogram was developed to provide an individualized risk assessment to predict CD in clinical practice, with excellent calibration and discriminative ability (Kolmogorov-Smirnov, D statistic, 0.29; 95% CI, 0.28 to 0.30) with a misclassification rate of 0.21 (95% CI, 0.19 to 0.25). CONCLUSION: Five parameters (maternal age, body mass index, height, fetal abdominal circumference, and fetal head circumference) can, in combination, be used to better determine the overall risk of CD in nulliparous women at term. A risk score can be used to inform women of their individualized probability of CD. This risk tool may be useful for reassuring most women regarding their likely success at achieving an uncomplicated vaginal delivery as well as selecting those patients with such a high risk for CD that they should avoid a trial of labor. Such a risk tool has the potential to greatly improve planning hospital service needs and minimizing patient risk.

Exercise and endometriosis-is there a promising future? A narrative review.

BACKGROUND: Endometriosis is the leading cause of chronic pelvic pain in women of reproductive age with debilitating effects on quality of life, yet no cure exists. Exercise yields the potential in providing women with a non-invasive, non-pharmacological method of symptom control. AIM(S): Present up-to-date knowledge regarding how exercise may contribute to the management of endometriosis-related symptoms. OBJECTIVE(S): Discuss: 1. The pathophysiology surrounding exercise and endometriosis. 2. The role of exercise in endometriosis symptom control. RATIONALE: Scientific literature has alluded to exercise being a favourable factor in the management of endometriosis-related symptoms. Moreover, current clinical guidelines for endometriosis fail to reflect the aforementioned benefits of exercise. SEARCH STRATEGY: A search strategy using the terms 'endometriosis', 'endometriomas', 'exercise', and 'physical activity' was devised. Pubmed, Medline, Cochrane reviews, and Embase were reviewed. INCLUSION CRITERIA: Interventional studies, within-subjects studies, randomised-control trials, systematic reviews, meta-analysis, cohort studies, publication since 2000. EXCLUSION CRITERIA: Non-English publications, non-human studies. RESULTS: Numerous studies have suggested positive effects for endometriosis patients who performed exercise exclusively or in conjunction with other therapies. Improvements in pain levels, quality of life, anxiety, and depression were noted. DISCUSSION: Current research outlines promise regarding the potential benefit of exercise prescribing in patients with endometriosis as well as a synergy between exercise and hormonal therapies for the management of endometriosis-related symptoms. However, the current paucity of high-quality robust studies investigating these aspects of endometriosis management is an apparent obstacle to progression in this area. CONCLUSION: For clinicians to incorporate exercise in managing endometriosis, clear recommendations regarding advice and benefits are needed.

Prophylactic oxytocin for the third stage of labour to prevent postpartum haemorrhage.

BACKGROUND: Active management of the third stage of labour has been shown to reduce the risk of postpartum haemorrhage (PPH) greater than 1000 mL. One aspect of the active management protocol is the administration of prophylactic uterotonics, however, the type of uterotonic, dose, and route of administration vary across the globe and may have an impact on maternal outcomes. OBJECTIVES: To determine the effectiveness of prophylactic oxytocin at any dose to prevent PPH and other adverse maternal outcomes related to the third stage of labour. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2013). SELECTION CRITERIA: Randomised or quasi-randomised controlled trials including pregnant women anticipating a vaginal delivery where prophylactic oxytocin was given during management of the third stage of labour. The primary outcomes were blood loss > 500 mL and the use of therapeutic uterotonics. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion, assessed trial quality and extracted data. Data were checked for accuracy. MAIN RESULTS: This updated review included 20 trials (involving 10,806 women). Prophylactic oxytocin versus placebo Prophylactic oxytocin compared with placebo reduced the risk of PPH greater than 500 mL, (risk ratio (RR) 0.53; 95% confidence interval (CI) 0.38 to 0.74; six trials, 4203 women; T² = 0.11, I² = 78%) and the need for therapeutic uterotonics (RR 0.56; 95% CI 0.36 to 0.87, four trials, 3174 women; T² = 0.10, I² = 58%). The benefit of prophylactic oxytocin to prevent PPH greater than 500 mL was seen in all subgroups. Decreased use of therapeutic uterotonics was only seen in the following subgroups: randomised trials with low risk of bias (RR 0.58; 95% CI 0.36 to 0.92; three trials, 3122 women; T² = 0.11, I² = 69%); trials that performed active management of the third stage (RR 0.39; 95% CI 0.26 to 0.58; one trial, 1901 women; heterogeneity not applicable); trials that delivered oxytocin as an IV bolus (RR 0.57; 95% CI 0.39 to 0.82; one trial, 1000 women; heterogeneity not applicable); and in trials that gave oxytocin at a dose of 10 IU (RR 0.48; 95% CI 0.33 to 0.68; two trials, 2901 women; T² = 0.02, I² = 27%). Prophylactic oxytocin versus ergot alkaloids. Prophylactic oxytocin was superior to ergot alkaloids in preventing PPH greater than 500 mL (RR 0.76; 95% CI 0.61 to 0.94; five trials, 2226 women; T² = 0.00, I² = 0%). The benefit of oxytocin over ergot alkaloids to prevent PPH greater than 500 mL only persisted in the subgroups of quasi-randomised trials (RR 0.71, 95% CI 0.53 to 0.96; three trials, 1402 women; T² = 0.00, I² = 0%) and in trials that performed active management of the third stage of labour (RR 0.58; 95% CI 0.38 to 0.89; two trials, 943 women; T² = 0.00, I² = 0%). Use of prophylactic oxytocin was associated with fewer side effects compared with use of ergot alkaloids; including decreased nausea between delivery of the baby and discharge from the labour ward (RR 0.18; 95% CI 0.06 to 0.53; three trials, 1091 women; T² = 0.41, I² = 41%) and vomiting between delivery of the baby and discharge from the labour ward (RR 0.07; 95% CI 0.02 to 0.25; three trials, 1091 women; T² = 0.45, I² = 30%). Prophylactic oxytocin + ergometrine versus ergot alkaloids: There was no benefit seen in the combination of oxytocin and ergometrine versus ergometrine alone in preventing PPH greater than 500 mL (RR 0.90; 95% CI 0.34 to 2.41; five trials, 2891 women; T² = 0.89, I² = 80%). The use of oxytocin and ergometrine was associated with increased mean blood loss (MD 61.0 mL; 95% CI 6.00 to 116.00 mL; fixed-effect analysis; one trial, 34 women; heterogeneity not applicable).In all three comparisons, there was no difference in mean length of the third stage or need for manual removal of the placenta between treatment arms. AUTHORS' CONCLUSIONS: Prophylactic oxytocin at any dose decreases both PPH greater than 500 mL and the need for therapeutic uterotonics compared to placebo alone. Taking into account the subgroup analyses from both primary outcomes, to achieve maximal benefit providers may opt to implement a practice of giving prophylactic oxytocin as part of the active management of the third stage of labour at a dose of 10 IU given as an IV bolus. If IV delivery is not possible, IM delivery may be used as this route of delivery did show a benefit to prevent PPH greater than 500 mL and there was a trend to decrease the need for therapeutic uterotonics, albeit not statistically significant.Prophylactic oxytocin was superior to ergot alkaloids in preventing PPH greater than 500 mL; however, in subgroup analysis this benefit did not persist when only randomised trials with low risk of methodologic bias were analysed. Based on this, there is limited high-quality evidence supporting a benefit of prophylactic oxytocin over ergot alkaloids. However, the use of prophylactic oxytocin was associated with fewer side effects, specifically nausea and vomiting, making oxytocin the more desirable option for routine use to prevent PPH.There is no evidence of benefit when adding oxytocin to ergometrine compared to ergot alkaloids alone, and there may even be increased harm as one study showed evidence that using the combination was associated with increased mean blood loss compared to ergot alkaloids alone.Importantly, there is no evidence to suggest that prophylactic oxytocin increases the risk of retained placenta when compared to placebo or ergot alkaloids.More placebo-controlled, randomised, and double-blinded trials are needed to improve the quality of data used to evaluate the effective dose, timing, and route of administration of prophylactic oxytocin to prevent PPH. In addition, more trials are needed especially, but not only, in low- and middle-income countries to evaluate these interventions in the birth centres that shoulder the majority of the burden of PPH in order to improve maternal morbidity and mortality worldwide.

Has highly active antiretroviral therapy increased the time to seroreversion in HIV exposed but uninfected children?

BACKGROUND: Since the introduction of highly active antiretroviral therapy (HAART) for prevention of mother-to-child transmission of human immunodeficiency virus (HIV) in pregnancy in the United States, the time of seroreversion in infants born to HIV-infected mothers has not been documented. The objective of this study was to determine the timing of clearance of HIV antibodies and to identify any associated biological and clinical factors. METHODS: A retrospective analysis of infants who remained uninfected after perinatal HIV exposure was performed. Infant and maternal medical records from January 2000 to December 2007 were reviewed and the time of seroreversion was estimated using methods for censored survival data. RESULTS: In total, 744 infants were included in the study, with prenatal data available for 551 mothers. The median age of seroreversion was 13.9 months, and 14% of infants remained seropositive after 18 months, 4.3% after 21 months, and 1.2% after 24 months. Earlier age of seroreversion was associated with higher immunoglobulin G (IgG) levels at 3-7 months of age (P = .0029) and a higher rate of IgG change over the next 6 months of life (P = .003). Infants born by vaginal delivery were more likely to serorevert at a younger age (P = .0052), and maternal exposure to protease inhibitors was associated with a later age of seroreversion (P = .026). CONCLUSIONS: Clearance of HIV antibodies in uninfected infants was found to occur at a later age than has been previously reported. Fourteen percent of the infants had persistence of HIV antibodies at or beyond 18 months of age.

Duration of membrane rupture and risk of perinatal transmission of HIV-1 in the era of combination antiretroviral therapy.

OBJECTIVE: The objective of the study was to determine whether the duration of membrane rupture of 4 or more hours is a significant risk factor for perinatal transmission of human immunodeficiency virus (HIV) in the era of combination antiretroviral therapy (ART). STUDY DESIGN: This was a prospective cohort study of 717 HIV-infected pregnant women-infant pairs with a delivery viral load available who received prenatal care and delivered at our institution during the interval 1996-2008. RESULTS: The cohort comprised 707 women receiving ART who delivered during this interval. The perinatal transmission rate was 1% in women with membranes ruptured for less than 4 hours and 1.9% when ruptured for 4 or more hours. For 493 women with a delivery viral load less than 1000 copies/mL receiving combination ART in pregnancy, there were no cases of perinatal transmission identified up to 25 hours of membrane rupture. Logistic regression demonstrated only a viral load above 10,000 copies/mL as an independent risk factor for perinatal transmission. CONCLUSION: Duration of membrane rupture of 4 or more hours is not a risk factor for perinatal transmission of HIV in women with a viral load less than 1000 copies/mL receiving combination ART.

Pharmacokinetics and safety of single-dose tenofovir disoproxil fumarate and emtricitabine in HIV-1-infected pregnant women and their infants.

Tenofovir (TFV) is effective in preventing simian immunodeficiency virus (SIV) transmission in a macaque model, is available as the oral agent tenofovir disoproxil fumarate (TDF), and may be useful in the prevention of mother-to-child transmission of human immunodeficiency virus (HIV). We conducted a trial of TDF and TDF-emtricitabine (FTC) in HIV-infected pregnant women and their infants. Women received a single dose of either 600 mg TDF, 900 mg TDF, or 900 mg TDF-600 mg FTC at labor onset or prior to a cesarean section. Infants received no drug or a single dose of TDF at 4 mg/kg of body weight or of TDF at 4 mg/kg plus FTC at 3 mg/kg as soon as possible after birth. All regimens were safe and well tolerated. Maternal areas under the serum concentration-time curve (AUC) and concentrations at the end of sampling after 24 h (C(24)) were similar between the two doses of TDF; the maximum concentrations of the drugs in serum (C(max)) and cord blood concentrations were higher in women delivering via cesarean section than in those who delivered vaginally (P = 0.04 and 0.046, respectively). The median ratio of the TFV concentration in cord blood to that in the maternal plasma at delivery was 0.73 (range, 0.26 to 1.95). Without TDF administration, infants had a median TFV concentration of 12 ng/ml 12 h after birth. Following administration of a single dose of TDF at 4 mg/kg, infant TFV concentrations fell below the targeted level, 50 ng/ml, by 24 h postdose. In HIV-infected pregnant women and their infants, 600 mg of TDF is acceptable as a single dose during labor. Low concentrations at birth support infant dosing as soon after birth as possible. Rapidly decreasing TFV levels in infants suggest that multiple or higher doses of TDF will be necessary to maintain concentrations that are effective for viral suppression.

A risk-prediction model using parameters of maternal body composition to identify gestational diabetes mellitus in early pregnancy.

BACKGROUND: Accurate early risk-prediction for gestational diabetes mellitus (GDM) would target intervention and prevention in women at the highest risk. We evaluated maternal risk-factors and parameters of body-composition to develop a prediction model for GDM in early gestation. METHODS: A prospective observational study was undertaken. Pregnant women aged between 18 and 50 y of age with gestational age between 10 and 16 weeks were included in the study. Women aged ≤18 y, twin-pregnancies, known foetal anomaly or pre-existing condition affecting oedema status were excluded. 8-point-skinfold thickness (SFT), mid-upper-arm-circumference (MUAC), waist, hip, weight and ultrasound measurements of subcutaneous (SAT) and visceral abdominal-adipose (VAT) were measured. Oral-glucose-tolerance-test (OGTT) for GDM diagnosis was undertaken at 28 weeks gestation. Binomial logistic-regression models were used to predict GDM. ROC-analysis determined discrimination and concordance of model and individual variables. RESULTS: 188 women underwent OGTT at ~28 weeks gestation. 20 women developed GDM. BMI (24.7 kg m-2 (±6.1), 29.9 kg m-2 (±7.8), p = 0.022), abdominal SAT(1.32 cm (CI 1.31, 1.53), 1.99 cm (CI 1.64, 2.31), p = 0.027), abdominal VAT(0.78 cm (CI 0.8, 0.96), 1.41 cm (CI 1.11, 1.65), p = 0.002), truncal SFT (84.8 mm (CI 88.2, 101.6), 130.4 mm (CI 105.1, 140.1), p = 0.010), waist (79.8 cm (CI 80.3, 84.1), 90.3 cm (CI 85.9, 96.2), p = 0.006) and gluteal hip (94.3 cm (CI 93.9, 98.0), 108.6 cm (CI 99.9, 111.6), p = 0.023) were higher in GDM vs. non-GDM. After screening variables for inclusion into the multivariate model, family history of diabetes, previous perinatal death, overall insulin resistant condition, abdominal SAT and VAT, 8-point SFT, MUAC and weight were included. The combined multivariate prediction model achieved an excellent level of discrimination, with an AUC of 0.860 (CI 0.774, 0.945) for GDM. CONCLUSIONS: An early gestation risk prediction model, incorporating known risk-factors, and parameters of body-composition, accurately identify pregnant women in their first-trimester who developed GDM later on in gestation. This methodology could be used clinically to identify at-risk pregnancies, and target specific treatment through referred services to those mothers who would most benefit.

Feasibility study protocol of a pragmatic, randomised controlled pilot trial: membrane sweeping to prevent post-term pregnancy-the MILO Study.

BACKGROUND: Post-term pregnancy is associated with an increased risk of maternal complications, respiratory distress and trauma to the neonate. Amniotic membrane sweeping has been recommended as a simple procedure to promote the spontaneous onset of labour. However, despite its widespread use, there is an absence of evidence on (a) its effectiveness and (b) its optimal timing and frequency. The primary aim of the MILO Study is to inform the optimal design of a future definitive randomised trial to evaluate the effectiveness (including optimal timing and frequency) of membrane sweeping to prevent post-term pregnancy. We will also assess the acceptability and feasibility of the proposed trial interventions to clinicians and women (through focus group interviews). METHODS/DESIGN: Multicentre, pragmatic, parallel-group, pilot randomised controlled trial with an embedded factorial design. Pregnant women with a live, singleton foetus ≥ 38 weeks gestation; cephalic presentation; longitudinal lie; intact membranes; English speaking and ≥ 18 years of age will be randomised in a 2:1 ratio to membrane sweep versus no membrane sweep. Women allocated randomly to a sweep will then be randomised further (factorial component) to early (from 39 weeks) versus late (from 40 weeks) sweep commencement and a single versus weekly sweep. The proposed feasibility study consists of four work packages, i.e. (1) a multicentre, pilot randomised trial; (2) a health economic analysis; (3) a qualitative study; and (4) a study within the host trial (a SWAT). Outcomes to be collected include recruitment and retention rates, compliance with protocol, randomisation and allocation processes, attrition rates and cost-effectiveness. Focus groups will be held with women and clinicians to explore the acceptability and feasibility of the proposed intervention, study procedures and perceived barriers and enablers to recruitment. DISCUSSION: The primary aim of the MILO Study is to inform the optimal design of a future definitive randomised trial to evaluate the effectiveness (including optimal timing and frequency) of membrane sweeping to prevent post-term pregnancy. Results will inform whether and how the design of the definitive trial as originally envisaged should be delivered or adapted. TRIAL REGISTRATION: ClinicalTrials.gov NCT04307199 . Registered on 12 March 2020.

The prediction of morbidity related to vaginal delivery in nulliparous women - A secondary analysis from the genesis multicenter trial.

OBJECTIVE: In the prospective multicenter Genesis study, we developed a prediction model for Cesarean delivery (CD) in term nulliparous women. The objective of this secondary analysis was to determine whether the Genesis model has the potential to predict maternal and neonatal morbidity associated with vaginal delivery. STUDY DESIGN: The national prospective Genesis trial recruited 2,336 nulliparous women with a vertex presentation between 39 + 0- and 40 + 6-weeks' gestation from seven tertiary centers. The prediction model used five parameters to assess the risk of CD: maternal age, maternal height, body mass index, fetal head circumference and fetal abdominal circumference. Simple and multiple logistic regression analyses were used to develop the Genesis model. The risk score calculated using this model were correlated with maternal and neonatal morbidity in women who delivered vaginally: postpartum hemorrhage (PPH), obstetric anal sphincter injury (OASI), shoulder dystocia, one- and five-minute Apgar score ≤ 7, neonatal intensive care (NICU) admission, cephalohematoma, fetal laceration, nerve palsy and fractures. The morbidities associated with spontaneous vaginal delivery were compared with those associated with operative vaginal delivery (OVD). The likelihood ratios for composite morbidity and the morbidity associated with OVD based on the Genesis risk scores were also calculated. RESULTS: A total of 1,845 (79%) nulliparous women had a vaginal delivery. A trend of increasing intervention and morbidity was observed with increasing Genesis risk score, including OVD (p < 0.001), PPH (p < 0.008), NICU admission (p < 0.001), low Apgar score at one-minute (p < 0.001) and OASI (p = 0.009). The morbidity associated with OVD was significantly higher compared to spontaneous vaginal delivery, including NICU admission (p < 0.001), PPH (p = 0.022), birth injury (p < 0.001), shoulder dystocia (p = 0.002) and Apgar score of<7 at one-minute (p < 0.001). The positive likelihood ratios for composite outcomes (where the OVD was excluded) increases with increasing risk score from 1.005 at risk score of 5% to 2.507 for risk score of>50%. CONCLUSION: In women who ultimately achieved a vaginal birth, we have shown more maternal and neonatal morbidity in the setting of a Genesis nomogram-determined high-risk score for intrapartum CD. Therefore, the Genesis prediction tool also has the potential to predict a more morbid vaginal delivery.

Small for gestational age infants and the association with placental and umbilical cord morphometry: a digital imaging study.

Introduction: Individual placental and umbilical cord morphometry have been previously identified to have an association with fetal growth. This study aims to identify which of the morphometric measurements in combination are associated with pregnancies with small for gestational age (SGA) infants using digital imaging of the delivered placenta.Material and methods: This study examined 1005 placentas from consecutively delivered singleton pregnancies in a tertiary center. Standardized images of each placenta were taken. Placental weight and thickness; umbilical cord length and diameter were measured on gross examination. Distance from the placental cord insertion site to placental margin, length and breadth of the placenta and placental chorionic surface area were measured digitally using ImageJ software. Logistic regression models and area under the curve (AUC) were used to identify the best subset of morphometric measurements to classify infants as SGA (<10th centile).Results: Overall, 141 (14%) infants were SGA. The morphometric measurements at delivery most strongly associated with the classification of infants as SGA were placental weight (AUC = 0.806) and placental surface area (AUC = 0.749). Of the potential antenatal morphometric measurements, umbilical cord diameters, both placental (AUC = 0.644) and fetal end (AUC = 0.629) were most strongly associated with SGA. A logistic regression model with maternal age, smoking status, current history of preeclampsia, umbilical cord length, placental weight, birthweight-to-placental weight ratio and umbilical cord diameter (placental end) had a sensitivity of 53% and a false-positive rate of 2% (AUC = 0.945) for the classification of infants as SGA.Conclusion: Placental and umbilical cord morphometry measured at delivery are different between SGA and non-SGA infants. Further studies are warranted to investigate the feasibility and accuracy of ultrasound to measure placental and umbilical cord morphometry during pregnancy.

Inter-hospital comparison of Cesarean delivery rates should not be considered to reflect quality of care without consideration of patient heterogeneity: An observational study.

OBJECTIVE: Contemporary approaches to monitoring quality of care in obstetrics often focus on comparing Cesarean Delivery rates. Varied rates can complicate interpretation of quality of care. We previously developed a risk prediction tool for nulliparous women who may require intrapartum Cesarean delivery which identified five key predictors. Our objective with this study was to ascertain if patient heterogeneity can account for much of the observed variation in Cesarean delivery rates, thereby enabling Cesarean delivery rates to be a better marker of quality of care. MATERIALS AND METHODS: This is a secondary analysis of the Genesis study. This was a large prospective study of 2336 nulliparous singleton pregnancies recruited at seven hospitals. A heterogeneity score was calculated for each hospital. An adjusted Cesarean delivery rate was also calculated incorporating the heterogeneous risk score. RESULTS: A cut-off at the 90th percentile was determined for each predictive factor. Above the 90th percentile was considered to represent 'high risk' (with the exception of maternal height which identified those below the 10th percentile). The patient heterogeneous risk score was defined as the number of risk factors > 90th percentile (<10th percentile for height). An unequal distribution of high-risk patients between centers was observed (p < 0.001). The correlation between the Cesarean delivery rate and the patient heterogeneous risk score was high (0.76, p < 0.05). When adjusted for patient heterogeneity, Cesarean delivery rates became closer aligned. CONCLUSION: Inter-institutional diversity is common. We suggest that crude comparison of Cesarean delivery rates between different hospitals as a marker of care quality is inappropriate. Allowing for marked differences in patient characteristics is essential for correct interpretation of such comparisons.

Amniocentesis prior to physical exam-indicated cerclage in women with midtrimester cervical dilation: results from the expectant management compared to Physical Exam-indicated Cerclage international cohort study.

We evaluated whether the performance of an amniocentesis in women with a dilated cervix presenting at less than 26 weeks and subsequently managed by a physical exam-indicated cerclage increases the risk of spontaneous preterm birth (PTB) less than 28 weeks. Women between 15 (0)/ (7) to 25 (6)/ (7) weeks' gestation with a dilated cervix (1 to 4 cm) were identified. Multiple exclusion criteria were designated. The primary outcome was PTB less than 28 weeks. One hundred twenty-two women with a dilated cervix between 15 and 25 (6)/ (7) weeks gestational age were identified. Twenty-four (20%) of these had an amniocentesis performed. The unadjusted rate of PTB < 28 weeks differed between women who underwent amniocentesis compared with those who did not (58% versus 34%, respectively, P = 0.02), but after multivariate regression analysis, the performance of an amniocentesis was not an independent contributor to PTB < 28 weeks ( P = 0.90). The performance of an amniocentesis prior to cerclage did not independently contribute to PTB less than 28 weeks.