Progression of diabetic retinopathy in women with pregestational diabetes during pregnancy and postpartum.

BACKGROUND: Diabetic retinopathy (DR) may worsen during pregnancy, but its course in the postpartum remains poorly understood. Understanding the natural history of DR during and after pregnancy can help determine when sight-threatening DR treatment should be administered. METHODS: A prospective longitudinal cohort study recruited pregnant women with pre-existing type 1 (T1D) or type 2 diabetes from two tertiary Diabetes Antenatal Clinics in Melbourne, Australia. Eye examination results in early pregnancy, late pregnancy, and up to 12-months postpartum were compared to determine DR changes. Two-field fundus photographs and optical coherence tomography scans were used to assess DR severity. RESULTS: Overall, 105 (61.4%) women had at least two eye examinations during the observation period. Mean age was 33.5 years (range 19-51); 54 women (51.4%) had T1D; 63% had HbA1c <7% in early pregnancy. DR progression rate was 23.8% (95% CI 16.4-32.6). Having T1D (RR 4.96, 95% CI 1.83-13.46), pre-existing DR in either eye (RR 4.54, 95% CI 2.39-8.61), and elevated systolic blood pressure (adjusted RR 2.49, 95% CI 1.10-5.66) were associated with increased risk of progression. Sight-threatening progression was observed in 9.5% of women. Among the 19 eyes with progression during pregnancy, 15 eyes remained stable, three eyes progressed, and only one eye regressed in the postpartum. CONCLUSIONS: Nearly 1 in 4 women had DR progression from conception through to 12-months postpartum; almost half of these developing sight-threatening disease. DR progression occurring during pregnancy was found to predominantly remain unchanged, or worsen, after delivery, with very few eyes spontaneously improving postpartum.

Prevalence of diabetic retinopathy in women with pregestational diabetes during pregnancy and the postpartum.

BACKGROUND: Diabetic retinopathy (DR) may be affected by pregnancy. The majority of prevalence data regarding DR in pregnancy predate the advent of contemporary guidelines for diabetes management during pregnancy. This study reports DR prevalence and associated risk factors in women with pregestational diabetes during pregnancy and the postpartum in Australia. METHODS: A total of 172 pregnant women with type 1 (T1DM) or type 2 diabetes diagnosed pre-pregnancy were prospectively recruited from two obstetrics hospitals in Melbourne (November 2017-March 2020). Eye examinations were scheduled in each trimester, at 3-, 6-, and 12-months postpartum. DR severity was graded from two-field fundus photographs by an independent grader utilising the Airlie House Classification. Sight-threatening DR (STDR) was defined as the presence of diabetic macular oedema or proliferative DR. RESULTS: Overall, 146 (84.9%) women had at least one eye examination during pregnancy. The mean age was 33.8 years (range 19-51), median diabetes duration was 7.0 years (IQR 3.0-17.0), 71 women (48.6%) had T1DM. DR and STDR prevalence during pregnancy per 100 eyes was 24.3 (95% CI 19.7-29.6) and 9.0 (95% CI 6.1-12.9); while prevalence in the postpartum was 22.2 (95% CI 16.5-29.3) and 10.0 (95% CI 5.4-17.9), respectively. T1DM, longer diabetes duration, higher HbA1c in early pregnancy, and pre-existing nephropathy were significant risk factors. CONCLUSIONS: The prevalence of DR in pregnant women was similar to the non-pregnant diabetic population in Australia. One in nine participants had STDR during pregnancy and the postpartum, highlighting the need to optimise DR management guidelines in pregnancy given the significant risk of vision loss.

Postpartum circulating microRNA enhances prediction of future type 2 diabetes in women with previous gestational diabetes.

AIMS/HYPOTHESIS: Type 2 diabetes mellitus is a major cause of morbidity and death worldwide. Women with gestational diabetes mellitus (GDM) have greater than a sevenfold higher risk of developing type 2 diabetes in later life. Accurate methods for postpartum type 2 diabetes risk stratification are lacking. Circulating microRNAs (miRNAs) are well recognised as biomarkers/mediators of metabolic disease. We aimed to determine whether postpartum circulating miRNAs can predict the development of type 2 diabetes in women with previous GDM. METHODS: In an observational study, plasma samples were collected at 12 weeks postpartum from 103 women following GDM pregnancy. Utilising a discovery approach, we measured 754 miRNAs in plasma from type 2 diabetes non-progressors (n = 11) and type 2 diabetes progressors (n = 10) using TaqMan-based real-time PCR on an OpenArray platform. Machine learning algorithms involving penalised logistic regression followed by bootstrapping were implemented. RESULTS: Fifteen miRNAs were selected based on their importance in discriminating type 2 diabetes progressors from non-progressors in our discovery cohort. The levels of miRNA miR-369-3p remained significantly different (p < 0.05) between progressors and non-progressors in the validation sample set (n = 82; 71 non-progressors, 11 progressors) after adjusting for age and correcting for multiple comparisons. In a clinical model of prediction of type 2 diabetes that included six traditional risk factors (age, BMI, pregnancy fasting glucose, postpartum fasting glucose, cholesterol and triacylglycerols), the addition of the circulating miR-369-3p measured at 12 weeks postpartum improved the prediction of future type 2 diabetes from traditional AUC 0.83 (95% CI 0.68, 0.97) to an AUC 0.92 (95% CI 0.84, 1.00). CONCLUSIONS: This is the first demonstration of miRNA-based type 2 diabetes prediction in women with previous GDM. Improved prediction will facilitate early lifestyle/drug intervention for type 2 diabetes prevention.

Extracellular vesicle-associated miRNAs are an adaptive response to gestational diabetes mellitus.

BACKGROUND: Gestational diabetes mellitus (GDM) is a serious public health issue affecting 9-15% of all pregnancies worldwide. Recently, it has been suggested that extracellular vesicles (EVs) play a role throughout gestation, including mediating a placental response to hyperglycaemia. Here, we investigated the EV-associated miRNA profile across gestation in GDM, assessed their utility in developing accurate, multivariate classification models, and determined the signaling pathways in skeletal muscle proteome associated with the changes in the EV miRNA profile. METHODS: Discovery: A retrospective, case-control study design was used to identify EV-associated miRNAs that vary across pregnancy and clinical status (i.e. GDM or Normal Glucose Tolerance, NGT). EVs were isolated from maternal plasma obtained at early, mid and late gestation (n = 29) and small RNA sequencing was performed. Validation: A longitudinal study design was used to quantify expression of selected miRNAs. EV miRNAs were quantified by real-time PCR (cases = 8, control = 14, samples at three times during pregnancy) and their individual and combined classification efficiencies were evaluated. Quantitative, data-independent acquisition mass spectrometry was use to establish the protein profile in skeletal muscle biopsies from normal and GDM. RESULTS: A total of 2822 miRNAs were analyzed using a small RNA library, and a total of 563 miRNAs that significantly changed (p < 0.05) across gestation and 101 miRNAs were significantly changed between NGT and GDM. Analysis of the miRNA changes in NGT and GDM separately identified a total of 256 (NGT-group), and 302 (GDM-group) miRNAs that change across gestation. A multivariate classification model was developed, based on the quantitative expression of EV-associated miRNAs, and the accuracy to correctly assign samples was > 90%. We identified a set of proteins in skeletal muscle biopsies from women with GDM associated with JAK-STAT signaling which could be targeted by the miRNA-92a-3p within circulating EVs. Interestingly, overexpression of miRNA-92a-3p in primary skeletal muscle cells increase insulin-stimulated glucose uptake. CONCLUSIONS: During early pregnancy, differently-expressed, EV-associated miRNAs may be of clinical utility in identifying presymptomatic women who will subsequently develop GDM later in gestation. We suggest that miRNA-92a-3p within EVs might be a protected mechanism to increase skeletal muscle insulin sensitivity in GDM.

Risk factors for pregnancy outcomes in Type 1 and Type 2 diabetes.

BACKGROUND: Understanding the risk factors and pregnancy outcomes in women affected by Type 1 and Type 2 diabetes is important for pre-pregnancy counselling. AIM: To explore differences in pregnancy outcomes between women with Type 1 and Type 2 diabetes, and healthy controls, and to examine the relationships between potential adverse risk factors and pregnancy outcomes in this cohort of women. METHODS: This is a 10-year retrospective study of women with Type 1 diabetes (n = 92), Type 2 diabetes (n = 106) and healthy women without diabetes (controls) (n = 119) from a tertiary obstetric centre. Clinical and biochemical characteristics of women with Type 1 and Type 2 diabetes were determined and related to major obstetric outcomes using univariate analysis. RESULTS: Women with pre-existing diabetes had higher adverse pregnancy outcomes (preeclampsia, emergency caesarean section, preterm birth <32 and 37 weeks, large for gestational age, neonatal jaundice, Apgar score < 7 at 5 min, neonatal intensive care admission and neonatal hypoglycaemia) compared to controls. A higher birth weight gestational centile (97.4% vs 72.4%, P = 0.001) and large for gestational age rate (63.4% vs 35.8%, P = 0.001) were observed in Type 1 diabetes compared to Type 2 diabetes. There were no differences in other outcomes between women with Type 1 and 2 diabetes. CONCLUSION: In this exploratory study, risk factors for maternal adverse outcomes differ between Type 1 and Type 2 diabetes. Maternal and foetal adverse outcomes were higher in pregnancies affected by diabetes compared to healthy women but occurred with similar frequency in women with Type 1 and Type 2 diabetes.

Obstetric and perinatal outcomes for women with pre-existing diabetes in rural compared to metropolitan settings in Victoria, Australia.

BACKGROUND: Pre-existing diabetes in pregnancy is associated with an increased risk of complications. Likewise, living in rural, regional and remote Victoria, Australia, is also associated with poorer health outcomes. There is a gap in the literature with regard to whether Victorian women with pre-existing diabetes experience a greater risk of adverse pregnancy outcomes compared to their metropolitan counterparts. AIM: Our objective is to compare obstetric and perinatal outcomes for women with pre-existing diabetes delivering in rural vs metropolitan hospitals in Victoria, Australia. MATERIALS AND METHODS: Retrospective population-based study using routinely collected state-based data of singleton births to women with type 1 and type 2 diabetes who delivered in metropolitan (n = 3233) and rural hospitals (n = 693) in Victoria, Australia, between 2006-2015. Pearson's χ2 test, Fisher's exact test and MannWhitney U-test were used to compare obstetric and perinatal outcomes between metropolitan and rural locations. RESULTS: Delivery in a rural hospital was associated with higher rates of stillbirth (2.3% vs 1.1%, P = 0.027), macrosomia (25.9% vs 16.9%, P < 0.001), shoulder dystocia (8.4% vs 3.5%, P < 0.001) and admission to the neonatal intensive care unit/special care nursery (73.2% vs 59.3%, P < 0.001). Smoking (18.0% vs 8.9%, P < 0.001), overweight/obesity (P = 0.047) and socioeconomic disadvantage (P < 0.001) were more common in rural women. CONCLUSIONS: Women with pre-existing diabetes who deliver in rural hospitals experience a greater risk of adverse perinatal outcomes and present with increased maternal risk factors. These results suggest a need to improve care for women with pre-existing diabetes in rural Victoria.

Pregestational diabetes in pregnancy: Complications, management, surveillance, and mechanisms of disease-A review.

Diabetes is an increasingly common diagnosis among pregnant women. Pregestational diabetes is associated with an increase in many adverse pregnancy outcomes, which impact both on the woman and her fetus. The models of pregnancy care for women with diabetes are based largely on observational data or consensus opinion. Strategies for aneuploidy screening and monitoring for fetal well-being should be modified in women with diabetes. There is an increasing understanding of the mechanisms by which congenital anomalies and disorders of fetal growth occur, involving epigenetic modifications, changes in gene expression in critical developmental pathways, and oxidative stress. This knowledge may lead to pathways for improved care for these high-risk pregnancies.

A prospective review of perinatal mortality at Hospital Nacional Guido Valadares (HNGV).

BACKGROUND: Timor-Leste has one of the highest perinatal mortality rates in the Asia-Pacific region. Consistent and accurate data collection improves understanding of perinatal outcomes and facilitates the development of interventions to reduce stillbirths and early neonatal deaths. AIMS: (1) To identify changes in the rates of stillbirth and early neonatal deaths from previous published data. (2) To determine if prospective data collection and the application of the simplified Causes Of Death and Associated Conditions (CODAC) classification allows better identification of perinatal deaths in Timor-Leste. METHODS: A prospective audit of perinatal deaths of women delivering at Hospital Nacional Guido Valadares (HNGV) was undertaken from January to June 2016 inclusive. The hospital birth registry, maternal and neonatal records were reviewed to determine the most likely aetiology and classification of perinatal deaths using the simplified CODAC system. RESULTS: One hundred and ten stillbirths and 28 early neonatal deaths were identified. Fifty-four percent of perinatal deaths occurred antepartum, 26% intrapartum and 20% were early neonatal deaths. Cause of death among stillbirths could not be ascertained in 40% of cases. Intrapartum asphyxia was the commonest identified aetiology of intrapartum and early neonatal deaths. CONCLUSION: There has been limited improvement in the rate of stillbirths and early neonatal deaths at HNGV. Intrapartum hypoxia and maternal hypertensive conditions were the most common identified aetiologies highlighting areas where targeted interventions may help reduce high perinatal mortality rates. Aetiology of perinatal deaths, particularly antepartum stillbirths was difficult to discern even when well-tested classification systems are used.

Gestational weight gain outside the Institute of Medicine recommendations and adverse pregnancy outcomes: analysis using individual participant data from randomised trials.

BACKGROUND: High Body Mass Index (BMI) and gestational weight gain (GWG) affect an increasing number of pregnancies. The Institute of Medicine (IOM) has issued recommendations on the optimal GWG for women according to their pre-pregnancy BMI (healthy, overweight or obese). It has been shown that pregnant women rarely met the recommendations; however, it is unclear by how much. Previous studies also adjusted the analyses for various women's characteristics making their comparison challenging. METHODS: We analysed individual participant data (IPD) of healthy women with a singleton pregnancy and a BMI of 18.5 kg/m2 or more from the control arms of 36 randomised trials (16 countries). Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were used to describe the association between GWG outside (above or below) the IOM recommendations (2009) and risks of caesarean section, preterm birth, and large or small for gestational age (LGA or SGA) infants. The association was examined overall, within the BMI categories and by quartile of GWG departure from the IOM recommendations. We obtained aOR using mixed-effects logistic regression, accounting for the within-study clustering and a priori identified characteristics. RESULTS: Out of 4429 women (from 33 trials) meeting the inclusion criteria, two thirds gained weight outside the IOM recommendations (1646 above; 1291 below). The median GWG outside the IOM recommendations was 3.1 kg above and 2.7 kg below. In comparison to GWG within the IOM recommendations, GWG above was associated with increased odds of caesarean section (aOR 1.50; 95%CI 1.25, 1.80), LGA (2.00; 1.58, 2.54), and reduced odds of SGA (0.66; 0.50, 0.87); no significant effect on preterm birth was detected. The relationship between GWG below the IOM recommendation and caesarean section or LGA was inconclusive; however, the odds of preterm birth (1.94; 1.31, 2.28) and SGA (1.52; 1.18, 1.96) were increased. CONCLUSIONS: Consistently with previous findings, adherence to the IOM recommendations seem to help achieve better pregnancy outcomes. Nevertheless, even in the context of clinical trials, women find it difficult to adhere to them. Further research should focus on identifying ways of achieving a healthier GWG as defined by the IOM recommendations.

Pregnancy outcomes for women with pre-pregnancy diabetes mellitus in Australian populations, rural and metropolitan: A review.

BACKGROUND: Historically, pre-pregnancy diabetes (PPDM) is a recognised risk factor for poor pregnancy outcome. Co-existing pathology and adverse social determinants including rural-metropolitan inequities in health and healthcare access may confer additional risks. Multidisciplinary care before, during and after pregnancy can improve outcomes for women with PPDM and their infants. The extent to which rural Australian women and their families share in improved outcomes is unknown. We aimed to summarise maternal characteristics and pregnancy outcomes for women with PPDM, including women in rural settings and examine applications of existing clinical guidelines to rural Australian practice. METHODS: We sought English language population and cohort studies about PPDM using Medline, Embase, PubMed, Australian epidemiological and international clinical practice guidelines. RESULTS: Women with PPDM are changing: older, more obese, of lower parity, less likely to smoke, more likely to have type 2 rather than type 1 diabetes and shorter duration of PPDM. Women with PPDM continue to experience excess adverse pregnancy outcomes, including maternal morbidity, complicated birth, perinatal loss, congenital anomalies and mother-infant separation. On face value, clinical guidelines appear relevant to women living in rural settings but there are only a few, conflicting outcome studies for rural women with PPDM. CONCLUSIONS: PPDM is changing. A significant minority live in rural locations, and although perinatal mortality/morbidity seems to be improving, it is unclear if this is also true for rural women due to a lack of recent Australian studies. Further research is necessary to achieve excellence everywhere for women with PPDM and their babies.

Timing of diagnosis of gestational diabetes and pregnancy outcomes: A retrospective cohort.

BACKGROUND: Recent guidelines suggest screening high-risk women in early pregnancy for gestational diabetes (GDM); however, there is little evidence to support this. AIMS: To compare pregnancy outcomes associated with diabetes for women with risk factors for GDM according to gestation of diagnosis. Early GDM was defined as a positive test before 20 weeks gestation, late GDM as a positive test at 20 or more weeks and no GDM when both tests were negative. MATERIALS AND METHODS: Retrospective analysis in an Australian tertiary hospital of women who underwent a glucose tolerance test in pregnancy prior to 20 weeks gestation, and a repeat test after 20 weeks gestation if the initial test was negative. Results were adjusted for maternal demographics. RESULTS: Women with early GDM (n = 170) were no more likely to experience the obstetric composite outcome than women with late GDM (n = 171) or no GDM (n = 547) (early odds ratio (OR) 1.16, 95%CI 0.79-1.71; late OR 0.78, 95%CI 0.53-1.12). Infants of women with early GDM, but not late GDM, were more likely (early OR 1.8, 95%CI 1.15-2.92; late OR 1.4, 95%CI 0.90-2.23) to have the neonatal composite outcome than infants of women without GDM, predominantly due to an increase in neonatal hypoglycaemia. CONCLUSIONS: This result may be due to careful management of GDM, or because, after adjustment for maternal demographics, the early diagnosis of GDM does not substantially increase rates of adverse outcomes compared to GDM diagnosed in later pregnancy or no GDM in women with risk factors for GDM.

Planned early delivery versus expectant management for monoamniotic twins.

BACKGROUND: Monoamniotic twin pregnancies are formed when a single egg is fertilised and the resulting inner cell mass splits to form twins sharing the same amniotic sac. This condition is rare and affects about one in 10,000 pregnancies overall. Monoamniotic twin pregnancies are susceptible to complications including cord entanglement, increased congenital anomalies, intrauterine growth restriction, twin-to-twin transfusion syndrome and increased perinatal mortality. All twin pregnancies also carry additional maternal risks including pre-eclampsia, anaemia, antepartum haemorrhage, postpartum haemorrhage and operative delivery.The optimal timing for the delivery of monoamniotic twins is not known. The options include 'planned early delivery' between 32 and 34 weeks, or alternatively awaiting spontaneous labour at least up until the usual time of planned delivery for other monochorionic twins (approximately 36 to 38 weeks' gestation), unless there is a specific indication for earlier delivery. OBJECTIVES: To assess whether routine early delivery in monoamniotic twin pregnancies improves fetal, neonatal or maternal outcomes compared with 'expectant management'. Expectant management means awaiting spontaneous labour at least up until the usual time of planned delivery for other monochorionic twins (approximately 36 to 38 weeks' gestation in many centres), unless a specific indication for delivery occurs in the meantime, e.g. for non-reassuring antenatal testing. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2015). SELECTION CRITERIA: Published and unpublished randomised controlled trials (including cluster-randomised trials) comparing outcomes for women and infants who were randomised to planned early delivery of a monoamniotic twin pregnancy with outcomes for women and infants who were randomised to either planned term delivery or expectant management. However, we did not identify any trials for inclusion in this review.Quasi-randomised controlled trials, trials published in abstract form only, and trials using a cross-over design are not eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS: No trials were identified by the search strategy. MAIN RESULTS: No trials were identified by the search strategy. AUTHORS' CONCLUSIONS: Monoamniotic twins are rare, and there is insufficient randomised controlled evidence on which to draw strong conclusions about the best management. In their absence, we can refer to historical case series and expert consensus. Management plans should take into consideration the availability of high-quality neonatal care if early delivery is chosen. Women and their families should be involved in the decision making about these high-risk pregnancies.Ongoing, multicentre audits of maternal and perinatal outcomes for monoamniotic twins are needed in order to inform families and clinicians about up-to-date perinatal outcomes with contemporary obstetric practice. Research should consider the social and economic implications of planned interventions, as well as the perinatal outcomes.

Gestational weight gain information: seeking and sources among pregnant women.

BACKGROUND: Promoting healthy gestational weight gain (GWG) is important for preventing obstetric and perinatal morbidity, along with obesity in both mother and child. Provision of GWG guidelines by health professionals predicts women meeting GWG guidelines. Research concerning women's GWG information sources is limited. This study assessed pregnant women's sources of GWG information and how, where and which women seek GWG information. METHODS: Consecutive women (n = 1032) received a mailed questionnaire after their first antenatal visit to a public maternity hospital in Melbourne, Australia. Recalled provision of GWG guidelines by doctors and midwives, recalled provided GWG goals, and the obtaining of GWG information and information sources were assessed. RESULTS: Participants (n = 368; 35.7% response) averaged 32.5 years of age and 20.8 weeks gestation, with 33.7% speaking a language other than English. One in ten women recalled receiving GWG guidelines from doctors or midwives, of which half were consistent with Institute of Medicine guidelines. More than half the women (55.4%) had actively sought GWG information. Nulliparous (OR 7.07, 95% CI = 3.91-12.81) and obese (OR 1.96, 95% CI = 1.05-3.65) women were more likely to seek information. Underweight (OR 0.29, 95% CI = 0.09-0.97) women and those working part time (OR 0.52, 95% CI = 0.28-0.97) were less likely to seek information. Most frequently reported GWG sources included the internet (82.7%), books (55.4%) and friends (51.5%). The single most important sources were identified as the internet (32.8%), general practitioners (16.9%) and books (14.9%). CONCLUSION: More than half of women were seeking GWG guidance and were more likely to consult non-clinician sources. The small numbers given GWG targets, and the dominance of non-clinical information sources, reinforces that an important opportunity to provide evidence based advice and guidance in the antenatal care setting is currently being missed.

A retrospective review of stillbirths at the national hospital in Timor-Leste.

BACKGROUND: Timor-Leste has high maternal and infant mortality rates. Estimates of stillbirths are unreliable and limited by poor collection of vital health statistics. Lack of accurate data impedes the development of interventions to address local determinants of stillbirth. AIMS: This study aimed to identify the rate, timing and causes of stillbirths at National Hospital Guido Valadares in Dili, Timor-Leste, between November 2009 and December 2010, during which data were available. METHODS: Hospital birth registry and maternal records were retrospectively reviewed to identify stillbirths during the study period. The simplified Cause of Death and Associated Conditions system was utilised to classify stillbirths. RESULTS: One hundred and fifty-three stillbirths were identified, producing a stillbirth rate of 29 per 1000 births. Of stillbirths with known timing, 70 (66.7%) occurred antepartum and 35 (33.3%) intrapartum. Cause of death could not be ascertained in 62.7% of cases due to poor or missing records. Where identified, the three most commonly classified causes of death were intrapartum fetal asphyxia, maternal infection and maternal hypertensive disorder. CONCLUSION: This study highlights the need for standardised recording and coding of perinatal deaths at HNGV. The high proportion of antenatal death transfers from community health centres demonstrates the need for community and hospital staff training to improve the quality of antenatal and intrapartum obstetric care. A prospective study of stillbirths is recommended to obtain reliable data on the determinants of stillbirths in Timor-Leste. These data would inform evidence-based interventions for the improvement of maternity and obstetric care in community and hospital settings.

Decreased fetal movements: Report from the International Stillbirth Alliance conference workshop.

Maternal reports of decreased fetal movement (DFM) are a common reason to present to maternity care and are associated with stillbirth and other adverse outcomes. Promoting awareness of fetal movements and prompt assessment of DFM has been recommended to reduce stillbirths. However, evidence to guide clinical management of such presentations is limited. Educational approaches to increasing awareness of fetal movements in pregnant women and maternity care providers with the aim of reducing stillbirths have recently been evaluated in a several large clinical trials internationally. The International Stillbirth Alliance Virtual Conference in Sydney 2021 provided an opportunity for international experts in fetal movements to share reports on the findings of fetal movement awareness trials, consider evidence for biological mechanisms linking DFM and fetal death, appraise approaches to clinical assessment of DFM, and highlight research priorities in this area. Following this workshop summaries of the sessions prepared by the authors provide an overview of understandings of fetal movements in maternity care at the current time and highlights future directions in fetal movement research.

Is that femur really short? A survey of current and best practice in fetal biometry.

A web-based survey of Royal Australian and New Zealand College of Obstetricians and Gynaecologists fellows and trainees enquired about fetal femur length reporting and found: 1 Heterogeneous (including unpublished) chart choices. 2 Popular charts are not always of highest quality. 3 z-score rarely used despite World Health Authority endorsement. Potential clinical risks include false-positive and false-negative diagnosis and confusion for both patient and staff. We recommend developing high-quality charts, publishing unpublished charts and describe methods to support best practice.

Umbilical artery Doppler flow: an examination of current and best practice.

A Web-based survey of Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) fellows and trainees who perform or act on umbilical artery Doppler showed heterogeneous reporting practices. Systolic: diastolic ratio is frequently used. Pulsatility index is favoured internationally and by many RANZCOG subspecialists. Unpublished charts are used more often than published. We summarise ideal methods of chart development but recognise that chart choice is guided by professional opinion leaders, day-to-day accessibility and other factors.

Do primigravidae and their carers have a realistic expectation of uncomplicated labour and delivery?: a survey of primigravidae in late pregnancy, obstetric staff and medical students.

BACKGROUND: Women who experience unexpected labour and birth interventions describe feeling distressed and have an increased risk of postnatal depression. Primigravidae who have an unrealistic expectation of labour and birth may be at higher risk of these outcomes. AIMS: To determine whether primigravidae and their carers have a realistic expectation of uncomplicated labour and birth. METHODS: One hundered and ninety-five primigravidae, 32 obstetricians, 76 midwives, 198 medical students prior to their obstetric term and 131 medical students after their obstetric term completed a short questionnaire about the likelihood of primigravid women undergoing spontaneous onset of labour, no augmentation of labour and a cephalic vaginal birth without instrumental assistance, defined as birth without intervention. This number was compared to the local published data. RESULTS: Overall, the study subjects believed that women had a 48% chance of birth without intervention, and a 26% chance of birth without intervention or perineal sutures. The statewide published figures for these two outcomes are 21 and 8%, respectively. Staff, both obstetric and midwifery, were more accurate than medical students who were in turn more accurate than pregnant women. Attendance at antenatal education classes by pregnant women did not improve accuracy. Level of experience did not improve accuracy by medical staff. Medical students were more accurate after teaching than before teaching. CONCLUSION: Primigravidae in late pregnancy and maternity staff do not have a realistic expectation of a labour and birth that is free from medical intervention. This may impact on choices women make about care in pregnancy and labour.