Attitudes About Extremely Preterm Birth Among Obstetric and Neonatal Health Care Professionals in England: A Qualitative Study.

Importance: Variation in attitudes between health care professionals involved in the counseling of parents facing extremely preterm birth (<24 wk gestational age) may lead to parental confusion and professional misalignment. Objective: To explore the attitudes of health care professionals involved in the counseling of parents facing preterm birth on the treatment of extremely preterm infants. Design, Setting, and Participants: This qualitative study used Q methods to explore the attitudes of neonatal nurses, neonatologists, midwives, and obstetricians involved in the care of extremely preterm infants in 4 UK National Health Service perinatal centers between February 10, 2020, and April 30, 2021. Each participating center had a tertiary level neonatal unit and maternity center. Individuals volunteered participation through choosing to complete the study following a presentation by researchers at each center. A link to the online Q study was emailed to all potential participants by local principal investigators. Participants ranked 53 statements about the treatment of extremely preterm infants in an online quasi-normal distribution grid from strongly agree (6) to strongly disagree (-6). Main Outcomes and Measures: Distinguishing factors per professional group (representing different attitudes) identified through by-person factor analysis of Q sort-data were the primary outcome. Areas of shared agreement (consensus) between professional groups were also explored. Q sorts achieving a factor loading of greater than 0.46 (P < .01) on a given factor were included. Results: In total, 155 health care professionals volunteered participation (128 [82.6%] women; mean [SD] age, 41.6 [10.2] years, mean [SD] experience, 14.1 [9.6] years). Four distinguishing factors were identified between neonatal nurses, 3 for midwives, 5 for neonatologists, and 4 for obstetricians. Analysis of factors within and between professional groups highlighted significant variation in attitudes of professionals toward parental engagement in decision-making, the perceived importance of potential disability in decision-making, and the use of medical technology. Areas of consensus highlighted that most professionals disagreed with statements suggesting disability equates to reduced quality of life. The statement suggesting the parents' decision was considered the most important when considering neonatal resuscitation was placed in the neutral (middistribution) position by all professionals. Conclusions and Relevance: The findings of this qualitative study suggest that parental counseling at extremely low gestations is a complex scenario further complicated by the differences in attitudes within and between professional disciplines toward treatment approaches. The development of multidisciplinary training encompassing all professional groups may facilitate a more consistent and individualized approach toward parental engagement in decision-making.

Obstetric Complications of Donor Egg Conception Pregnancies.

Ovum donation (OD) pregnancies are becoming increasingly common. Obstetric complications with IVF pregnancies are well documented. However, until recently OD had not previously been investigated as a separate subtype of this. It could be postulated that there may be more complications with OD pregnancies as the embryo is immunologically different to the mother. The subsequent allograft reactions can cause problems with placental development and function leading to pathology. Initial studies investigating OD pregnancies were inadequate due to small sample size and inappropriate control groups. Studies specifically comparing to spontaneous pregnancies alone are not suitable when we already know that IVF in itself increases the risk to both mother and baby. Recent research has optimised the control group by using women undergoing IVF with autologous ovum. Ovum donation has now been shown to be an independent risk factor for hypertensive disease in pregnancy, post-partum haemorrhage and increased risk of caesarean section. Neonatal outcomes are less clear-cut, although there is some evidence to suggest there is increased risk of small for gestational age babies and preterm delivery. It is now clear that OD pregnancies are higher risk than IVF pregnancies with autologous ovum and they should be treated as such. Women with ovum donation pregnancies should have obstetric-led care, in a unit which has ready access to both blood transfusion and cell salvage. Future research should investigate how to reduce the risk of ovum donation to these women.

Relapsed Hodgkin's lymphoma in pregnancy: A case review.

Hodgkin's lymphoma is rarely diagnosed in pregnancy, occurring in 1:6000 deliveries. However, improvements in survival and the use of less gonadotoxic treatments have increased the number of Hodgkin's lymphoma survivors becoming pregnant. Both de novo and relapsed Hodgkin's lymphoma in pregnancy pose difficult decisions for both clinicians and patients. This review discusses important diagnostic and treatment considerations of relapsed Hodgkin's lymphoma in pregnancy. We discuss a difficult case which illustrates these particular dilemmas and suggests the evidence behind different modalities of investigation and management.

Implementation of foetal fibronectin testing: Admissions, maternal interventions and costs at 1 year.

Foetal fibronectin testing (fFN) has a high negative predictive value for preterm delivery, but it has a cost implication. This two-stage prospective study evaluated the real patient costs and clinical impact of introducing the fFN test in women presenting acutely with threatened preterm labour in a tertiary UK obstetric hospital. Introduction of the fFN test for women with threatened preterm labour reduced antenatal admissions and in utero transfers, and reduced steroid treatment and tocolysis, even at 1 year after implementation. The total number of bed days for women with threatened preterm labour who did not deliver during admission fell from 132 (mean 8.8 days) to 25 days (mean 3.6 days). The mean cost of admission per woman before introduction of the fFN test was £1032 (95% CI £880 to £1184); after it was £339 (95% CI £261 to £417). In this small single centre study, the introduction of the test produced a cost saving of £693 per woman (95% CI, £464 to £922) which over 12 months potentially saves £74844 (95% CI £50,112 to £99,576). Further studies are needed to formally evaluate the cost-effectiveness of the fFN test and its impact on clinical decision-making in large populations.

Maternal satisfaction and acceptability of foetal electrocardiographic (STAN®) monitoring system.

OBJECTIVE: To assess the acceptability of the foetal electrocardiographic (STAN®) monitoring system by patients at a London Hospital, before its introduction into routine clinical care. METHOD: This was a prospective questionnaire-based study of patients who were monitored in labour by foetal electrocardiographic (STAN®) monitoring system. RESULTS: Ninety-three percent (CI 85, 98) of the patients felt that the midwife(s) responsible for their intrapartum care took time to explain why their babies were being monitored continuously in the first instance. Ninety-nine percent (CI 93, 99.9) of patients felt that the obstetricians explained why they were being monitored continuously in labour. After delivering and having been monitored with STAN® 95% (CI 87, 99) of women felt that it was an acceptable way of monitoring their babies in labour. CONCLUSION: In resource-limited organisation, such as the NHS, holistic approach to intrapartum care may sometimes feel difficult to achieve. However, with emphasis on women centred care and information sharing women are able to understand and comment on intrapartum monitoring systems.

Acceptability of the fetal electrocardiographic (STAN) monitoring system by staff at a high risk maternity unit.

AIMS: To assess staff acceptability of STAN monitoring system. METHODS: This was a prospective study of health care professionals involved in the first 18 months of STAN use at a high risk maternity unit. RESULTS: During the study period 75% of midwives and 80% of doctors questioned felt confident when interpreting STAN cases. A total of 88% of midwives and 90% of doctors felt adequately supported in their actual clinical use of the system. Of all the obstetricians who used the STAN, 95% felt it was an acceptable alternative to fetal blood sampling. One of the main complaints was poor signal quality which occurred in 16% of cases. As many as 97% of doctors and 96% of midwives considered STAN to be an acceptable way of monitoring high risk women after its introduction. CONCLUSIONS: Introduction of a new monitoring system to a high risk labor ward is possible, and acceptable to its staff. Constant practical and theoretical support and adherence to strict, easily understood guidelines is required.

HIV in pregnancy: a case of Pneumocystis (carinii) jiroveci pneumonia.

This review highlights the rising prevalence of HIV in pregnancy both in the developed and developing world. It focuses on the challenges of diagnosis and management of Pneumocystis (carinii) jiroveci pneumonia in an HIV-positive pregnant woman. Public health efforts need to continue addressing testing at the earliest opportunity, the psychosocial issues which impact negatively on the care of HIV-positive individuals and ways to reduce stigmatisation associated with this viral illness.

Experience of delivering women with HIV in an inner city London hospital 1994-2004.

The objective of this study was to compare deliveries in women with HIV at Homerton University Hospital with those in the general antenatal hospital population. The study was a retrospective case-note review of deliveries from 1994 to 2004 at an Inner City London Hospital, UK (Homerton University Hospital). In all, 113 deliveries were studied in 98 women with HIV. Compared with the general antenatal population, women with HIV were more likely to be from African backgrounds, describe inadequate housing and be without the support of a partner or family; 79.8% of deliveries in women with HIV were by caesarean section in comparison with 22.4% in the overall hospital population. A majority of women with HIV received antiretroviral therapy in pregnancy. Intercurrent medical and antenatal complications were uncommon and in a majority the postpartum periods were uncomplicated. A significantly higher proportion of women with HIV infection described a previous history of depression than in the general hospital population. There were two instances of vertical transmission of HIV. In conclusion, our observations suggest that with appropriate monitoring and management strategies, successful pregnancy outcomes can be achieved in a complex HIV-positive patient population.

Posterior reversible leukoencephalopathy in a case of postpartum eclampsia.

This case report describes an atypical presentation of eclampsia. A 26-year-old lady presented 5 days' postpartum with a series of grand mal seizures after an uneventful pregnancy and delivery. An MRI scan of the brain showed areas of low signal involving cerebral white matter and right cerebellum. Within 2 weeks, all symptoms and radiologic abnormalities had resolved.