Outcome evaluation of prophylactic internal iliac balloon occlusion in the management of patients with placenta accreta spectrum.

PURPOSE: To evaluate outcomes and complications of prophylactic internal iliac balloon occlusion (PIIBO) in the management of patients with placenta accreta spectrum (PAS) at a large regional referral centre. MATERIALS AND METHODS: A retrospective review of all PIIBO for PAS performed over a 12-year period (2010-2022). Information for analysis was gathered from the local RIS/PACS and clinical documentation. Collected data included patient demographics, indication for procedure, sheath insertion and removal time, total duration of balloon inflation and complications that occurred. RESULTS: 106 patients underwent temporary internal iliac artery balloon occlusion within the 12-year period. All procedures utilised bilateral common femoral artery punctures, 6Fr sheath and 5Fr Le Maitre occlusion balloons. Catheters were successfully positioned and balloons inflated in obstetric theatre following caesarean delivery in 100% of the cases. The uterus was conserved in every case. There was no maternal mortality or foetal morbidity. Twenty patients (18.9%) had some form of complication that required further intervention. Of these, 7(6.6%) had post-operative PPH, which was treated with uterine artery embolisation; and 13 (12.3%) had arterial thrombus which required aspiration thrombectomy. All procedures were technically successful with no long-term sequelae. CONCLUSION: PIIBO plays an important part in reducing morbidity and mortality in patients with PAS. Clear pathways and multidisciplinary team working is critical in the management of these patients to ensure that any complications are dealt with promptly to avoid long-term sequelae.

Continuous cardiotocography during labour: Analysis, classification and management.

The use of continuous intrapartum electronic fetal heart rate monitoring (EFM) using a cardiotocograph (CTG) was developed to enable obstetricians and midwives to analyse the changes of fetal heart rate during labour so as to institute timely intervention to avoid intrapartum hypoxic-ischaemic injury. Although CTG was initially developed as a screening tool to predict fetal hypoxia, its positive predictive value for intrapartum fetal hypoxia is approximately only 30%. Even though different international classifications have been developed with the aim of defining combinations of features that help predict intrapartum fetal hypoxia, the false-positive rate of the CTG is high (60%). Moreover, there has not been a demonstrable improvement in the rate of cerebral palsy or perinatal deaths since the introduction of CTG into clinical practice approximately 45 years ago. However, there has been a significant increase in intrapartum caesarean section and operative vaginal delivery rates. Unfortunately, existing guidelines employ the visual interpretation of CTG based on 'pattern recognition', which is fraught with inter- and intra-observer variability. Therefore, clinicians need to understand the physiology behind fetal heart rate changes and to respond to them accordingly, instead of purely relying on guidelines for management. It is very likely that such a 'physiology-based' approach would reduce unnecessary operative interventions and improve perinatal outcomes whilst reducing the need for 'additional tests' of fetal well-being.

Uterine artery Doppler at 30-33 weeks' gestation in the prediction of preeclampsia.

OBJECTIVE: To investigate the potential value of measuring uterine artery pulsatility index (PI) at 30-33 weeks' gestation in the prediction of preeclampsia (PE) developing at or after 34 weeks. METHODS: Screening study in singleton pregnancies at 30-33 weeks' gestation including 4,294 cases that were unaffected by PE, gestational hypertension (GH) or delivery of small for gestational age neonates (normal group), 145 that subsequently developed PE, with 37 cases requiring delivery at 34-37 weeks (intermediate-PE) and 108 delivering at or after 38 weeks (late-PE) and 161 that developed GH. The a priori risks for intermediate- and late-PE from maternal demographic characteristics and medical history were derived by logistic regression analysis. The a posteriori risks were calculated by combining the a priori risks with the likelihood ratios for uterine artery PI, which were calculated from fitted bivariate gaussian distributions. RESULTS: In screening for PE by a combination of maternal characteristics and uterine artery PI, the estimated detection rates of intermediate- and late-PE, at a false-positive rate of 10%, were 70.3 and 54.6%, respectively. CONCLUSION: Combined testing by maternal characteristics and uterine artery PI at 30-33 weeks could effectively identify women at high risk for subsequent development of PE.

Maternal serum placental growth factor, pregnancy-associated plasma protein-a and free ß-human chorionic gonadotrophin at 30-33 weeks in the prediction of pre-eclampsia.

OBJECTIVE: To investigate the potential value of maternal serum concentrations of free ß-human chorionic gonadotrophin (ß-hCG), pregnancy-associated plasma protein-A (PAPP-A) and placental growth factor (PlGF) at 30-33 weeks of gestation in the prediction of pre-eclampsia (PE) developing at or after 34 weeks. METHODS: Serum free ß-hCG, PAPP-A and PlGF were measured at 11-13 and at 30-33 weeks of gestation in a case-control study of 50 cases that developed PE at or after 34 weeks and 250 unaffected controls. The measured concentration of metabolites was converted into multiples of the unaffected median (MoM) and the MoM values in the PE and control groups were compared. RESULTS: At 11-13 weeks, serum PlGF and PAPP-A, but not free ß-hCG, were significantly lower in the PE group than in the controls (0.824, 0.748 and 0.857 vs. 1.000 MoM). At 30-33 weeks in the PE group, PlGF was reduced (0.356 MoM), free ß-hCG was increased (1.750 MoM), but PAPP-A was not significantly different (0.991 MoM) from control (1.000 MoM). In screening for PE at 30-33 weeks by a combination of maternal characteristics and serum PlGF, the estimated detection rates, at a false-positive rate of 10%, of intermediate PE (requiring delivery at 34-37 weeks) and late PE (with delivery after 37 weeks) were 85.7 and 52.8%, respectively. The performance of screening was not improved by the addition of free ß-hCG or the free ß-hCG/PlGF ratio. CONCLUSION: Screening by maternal characteristics and serum PlGF at 30-33 weeks could identify most pregnancies that will subsequently develop PE.

Maternal serum activin-A at 30-33 weeks in the prediction of preeclampsia.

OBJECTIVE: To investigate the potential value of maternal serum concentration of activin-A at 30-33 weeks' gestation in the prediction of preeclampsia (PE) developing at or after 34 weeks. METHODS: Serum concentrations of activin-A were measured at 11-13 and at 30-33 weeks' gestation in a case-control study of 50 cases that developed PE and 250 unaffected controls. The measured values of activin-A were converted into multiples of the unaffected median (MoM), after adjustment for maternal characteristics, and the MoM values in the PE and controls were compared. RESULTS: The median activin-A MoM at 30-33 weeks was higher in the PE group (1.47, IQR 1.14-2.38 versus 0.99, IQR 0.72-1.42), but at 11-13 weeks there was no significant difference between the groups. In screening by a combination of maternal characteristics and activin-A at 30-33 weeks the detection rate of PE was 50.0%, at a false positive rate of 10%. CONCLUSION: Screening by maternal characteristics and activin-A at 30-33 weeks could identify half of the pregnancies that will subsequently develop PE.

Haptoglobina: valor semiológico / Haptoglobin: seiologic value

Se estudian los valores normales y el comportamiento de la haptoglobina en varias enfermedades con una técnica referida por Henry y modificada por Grueiro. Se obtuvieron los siguientes resultados: los valores normales resultaron diferentes a los propuestos por el autor. Se expresa que los resultados obtenidos en las neoplasias malignas muestran los pacientes en etapas avanzadas. En general, en otras enfermedades mostró una alta frecuencia en pacientes que atravesaban un momento agudo de la enfermedad. Se recomienda utilizar esta técnica asistencialmente por su sencillez, economía y confiabilidad (AU)

Haptoglobina: valor semiológico / Haptoglobin: semiologic value

Se estudian los valores normales y el comportamiento de la haptoglobina en varias enfermedades con una técnica referida por Henry y modificada por Grueiro. Se obtuvieron los siguientes resultados: los valores normales resultaron diferentes a los propuestos por el autor. Se expresa que los resultados obtenidos en las neoplasias malignas muestran los pacientes en etapas avanzadas. En general, en otras enfermedades mostró una alta frecuencia en pacientes que atravesaban un momento agudo de la enfermedad. Se recomienda utilizar esta técnica asistencialmente por su sencillez, economía y confiabilidad