Transfusion for sickle cell disease in pregnancy: a single-centre survey.

INTRODUCTION: Sickle cell disease in pregnancy carries a high risk of maternal and fetal adverse outcomes. The use of prophylactic transfusions to reduce the risk of sickle complications is controversial. Current UK standards do not recommend the routine use of transfusion for sickle pregnancy. We examined transfusion episodes during sickle pregnancies in a single centre over an 11-year period. METHODS: We conducted a retrospective observational study of all pregnancies in patients with sickle cell disease who attended the joint obstetric/haematology clinic over an 11-year period. All pregnancies were managed according to a local protocol, which did not recommend routine transfusion. RESULTS: A total of 38 pregnancies (HbSS 22, HbSC 13, Hb S/beta thalassaemia 3) were included, with a mean age at booking of 29 years. A total of 61% of pregnancies required on-demand or emergency transfusion during the course of pregnancy or post-partum. Women requiring a transfusion during pregnancy had a higher mean number of hospital admissions in the previous year (1·11 vs 0·15, P = 0·057), a significantly lower mean steady-state haemoglobin (85·0 vs 99·6 g L-1 , P = 0·003) and a significantly lower mean haemoglobin at the pregnancy booking visit. (86·1 vs 99·5 g L-1 , P = 0·02). CONCLUSION: In sickle pregnancies assigned to standard management in a single centre, a high proportion of women required on-demand transfusion. Possible pre-pregnancy factors predictive of a need for transfusion include lower baseline haemoglobin and number of hospital admissions in the previous 12 months.

Facilitation of Vaginal Delivery in an Infant with Complete Heart Block Secondary to Maternal Anti-Ro Antibodies.

Congenital heart block (CHB) is a rare disorder that may be associated with a high morbidity and even mortality, with a risk of death both in utero and during infancy. Women with serum titres of anti-Ro and/or anti-La antibodies carry a risk of CHB of 1-5% in their offspring, with a recurrence risk of approximately 20%. We present a case of a 36-year-old female with a pregnancy complicated by congenital heart block. Autoimmune profiling at booking showed she was positive for lupus anticoagulant and anti-Ro antibodies. A fetal echocardiogram at 21 + 3 showed complete heart block. She was monitored throughout the remainder of her pregnancy with serial growth scans, cardiovascular profiling, and BPP scoring. She had a normal vaginal delivery at term to a female infant.

A critique of current practice of transvaginal pudendal nerve blocks: a prospective audit of understanding and clinical practice.

Pudendal nerve blocks are a pre-requisite to forceps delivery without regional anaesthesia. Their efficacy is dependent on introducing local anaesthetic in close proximity to the pudendal nerve and allowing sufficient time for its onset of action. An audit of 57 obstetricians evaluated their clinical technique against standards using both a questionnaire and adapted model pelvis. The majority of participants were unable to describe correctly the point of infiltration and were unaware of the lag time required to effect adequate analgesia. We identify a deficiency in training and describe a method by which training can be facilitated and assessed.

Identification of early predictive imaging biomarkers and their relationship to serological angiogenic markers in patients with ovarian cancer with residual disease following cytotoxic therapy.

BACKGROUND: Patients with recurrent ovarian cancer often achieve partial response following chemotherapy, resulting in persistent small volume disease. After completion of treatment, the dilemma of when to initiate subsequent chemotherapy arises. Identification of biomarkers that could be used to predict when subsequent treatment is needed would be of significant benefit. DESIGN: Twenty-three patients with advanced ovarian cancer and residual asymptomatic disease following chemotherapy underwent dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) at study entry, 4, 8, 12, 18 and 26 weeks or disease progression. A subgroup of patients provided plasma samples within which a panel of angiogenic biomarkers was quantified. RESULTS: By 4 weeks, significant differences in whole tumour volume, enhancing fraction and Ca125 were observed between patients whose disease progressed by 26 weeks and those who remained stable. Significant correlations between plasma soluble vascular endothelial growth factor receptor-1 (sVEGFR-1) and sVEGFR-2 concentrations, and blood volume and tumour endothelial permeability surface area product measured by DCE-MRI were observed. CONCLUSIONS: Imaging markers have a potential role in early prediction of disease progression in patients with residual ovarian cancer and may supplement current measures of progression. The correlation of DCE-MRI and serological biomarkers suggests that tumour angiogenesis affects these markers through common biological means and warrants further investigation.

Weekly paclitaxel in the treatment of recurrent ovarian carcinoma.

PURPOSE: To study the effect of weekly paclitaxel in the treatment of recurrent ovarian and peritoneal carcinoma. METHODS: A retrospective analysis of patients treated at Christie Cancer Centre between May 2003 and May 2005 was carried out. RESULTS: Fortynine patients with recurrent ovarian and peritoneal carcinoma were treated. The mean duration of treatment was 11 weeks, with 27 (54%) patients receiving 12 or more treatments. The most frequent non-haematological toxicities reported were mild nausea, constipation, lethargy and neuropathy. Moderate anaemia was noted in 50% of patients. Radiological assessment by CT scanning showed that complete or partial responses were achieved in 28% of patients. CA125 response was demonstrated in 63% of patients. Median time to recurrence was 149 days and median survival was 359 days. CONCLUSION: This study provides evidence for the role of weekly paclitaxel in the treatment of recurrent ovarian and peritoneal carcinoma even in a drug-resistant setting following multiple lines of prior therapy.

The interval from surgery to chemotherapy in the treatment of advanced epithelial ovarian carcinoma.

BACKGROUND: To study the effect of the interval between surgery and the start of chemotherapy in the treatment of patients with advanced ovarian cancer. METHODS: We stratified patients according to the start of platinum-based chemotherapy in group 1 (within 4 weeks from surgery), group 2 (between 4 and 8 weeks) and group 3 (between 8 and 12 weeks). RESULTS: Three hundred and ninty-four stage III ovarian cancer patients were analysed. In the multivariate analysis there were no differences in survival according to the interval between surgery and chemotherapy among the three groups. The independent prognostic variables were type of procedure (p = 0.014), performance status (p = 0.040) and post-chemotherapy CA-125 (p < 0.0001). CONCLUSIONS: The interval between surgery and chemotherapy does not affect outcome.

Is it possible to predict or prevent third degree tears?

OBJECTIVES: This paper reviews the causes anal sphincter injury during vaginal delivery. It emphasises that they are not usually the result of poor obstetric care. The role of the colorectal surgeon in their management is discussed. METHODS: Medline was searched using the key words third degree tears, pregnancy, risk factors, prevention and recurrence risk. A hand search of journals and located articles was made. Two hundred and twenty three papers were identified, 84 are referenced. RESULTS: The reported incidence of anal sphincter tears is usually between 0.5% and 2.5% of vaginal deliveries. Maternal factors such as parity and age and obstetric factors such as mode of presentation, the use of forceps and the size of the baby all influence the incidence of sphincter tears. Predicting tears in individual women is inaccurate and midwifery practices can do little to prevent them. Reducing pelvic floor morbidity by increasing the caesarean section rate would require that a large number of caesarean sections be done to prevent a small number of tears. The recognition of perineal trauma is improved by training. Accurate apposition of the sphincters with antibiotic cover and post-operative laxatives are the important technical aspects of the repair. Colorectal follow up helps to identify those women with symptoms and allows advice about the advisability of subsequent vaginal deliveries. A previous third degree tears increases the risk of a subsequent one, although the overall risk remains low. A second vaginal delivery after a third degree tear that has resulted in a functional deficit predisposes to worsening function. When there is no residual anatomical defect and no functional loss, there is no evidence of increased risk of incontinence following another vaginal delivery. CONCLUSION: Vaginal delivery will continue to be the main method of delivery and will continue to generate a low incidence of pelvic floor morbidity. The management of injury to the anal sphincter is facilitated by close co-operation between obstetricians and colorectal surgeons.