Obstetrician views on Fetal Pillow® device use and research in Aotearoa New Zealand: A cross-sectional survey.

BACKGROUND: There is anecdotal evidence of Fetal Pillow® use, but no formal local information on clinician practices and perspectives. AIMS: To assess obstetrician use of the Fetal Pillow®, knowledge of relevant research, and interest in a proposed randomised controlled trial in Aotearoa New Zealand. MATERIALS AND METHODS: Anonymous cross-sectional survey of practising obstetricians and obstetric trainees in Aotearoa New Zealand distributed by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists. RESULTS: Of 136 respondents (69% specialists and 31% trainees), 130 had heard of the Fetal Pillow® device, and 108 had used it at least once (43% more than ten times). The device was available in 17/21 units represented. The 108 users of the device reported this was most commonly on collegial advice (63%) or after personal experience of a difficult delivery (33%) and most (80%) believed it reduced maternal morbidity. Only around one-third of the 130 respondents who had heard of the device agreed there was adequate research demonstrating its efficacy for maternal (36%) and neonatal (30%) morbidity. The majority reported they would change practice in response to a randomised trial, although they were more likely to start use (81% of current non-users) than stop (53% of users). Most (70%) respondents agreed they would encourage patients to participate in a randomised trial. CONCLUSIONS: The Fetal Pillow® is available in most maternity units in Aotearoa New Zealand. The majority of obstetric clinicians believe it reduces maternal morbidity, while acknowledging the lack of scientific evidence. Most would support a randomised trial.

Maternal levels of care during pregnancy influence labor and delivery outcomes - present practices and future priorities.

Neonatal encephalopathy (NE) is a diagnosis that is usually unexpected. Though there are many risk factors for the condition and multiple theories as to its genesis, the majority of cases cannot be predicted prior to the occurrence of the clinical syndrome. Indeed, it is common for a pregnant person to have multiple risk factors and a completely healthy child. Conversely, people with seemingly no risk factors may go on to have a profoundly affected child. In this synopsis we review risk factors, potential mechanisms for encephalopathy, the complicated issue of choosing which morbidity to take on and how the maternal level of care may influence outcomes. The reader should be able to better understand the limitations of current testing and the profound levels of maternal intervention that have been undertaken to prevent or mitigate the rare, but devastating occurrence of NE. Further, we suggest candidate future approaches to prevent the occurrence, and decrease the severity of NE. Any future improvements in the NE syndrome cannot be achieved via obstetric intervention and management alone or conversely, by improvements in treatments offered post-birth. Multidisciplinary approaches that encompass prepregnancy health, pregnancy care, intrapartum management and postpartum care will be necessary.

Maternal and neonatal morbidity associated with Fetal Pillow® use at full dilatation caesarean: A retrospective cohort.

OBJECTIVE: To investigate associations of the Fetal Pillow® with maternal and neonatal morbidity. DESIGN: Retrospective cohort. SETTING: Two tertiary maternity units, New Zealand. POPULATION OR SAMPLE: Full dilatation singleton, term, cephalic caesarean section, with three comparisons: at Unit A (1) before versus after introduction of the Fetal Pillow® (1 Jaunary 2016-31 October 2021); (2) with versus without the Fetal Pillow® after introduction (27 July 2017-31 October 2021); and (3) between Unit A and Unit B during the same time period (1 January 2019-31 October 2021). The Fetal Pillow® is unavailable at Unit B. METHODS: Cases were ascertained and clinical data were extracted from electronic clinical databases and records. Outcome data were adjusted and presented as adjusted odds ratios (aOR) with 95% CI. MAIN OUTCOME MEASURES: Primary outcome "any" uterine incision extension; secondary outcomes included major extension (into adjacent structures), and a composite neonatal outcome. RESULTS: In all, 1703 caesareans were included; 375 with the device and 1328 without. Uterine incision extension rates were: at Unit A before versus after introduction: 26.8% versus 24.8% (aOR 0.88, 95% CI 0.65-1.19); at Unit A with the Fetal Pillow® versus without: 26.1% versus 23.8% (aOR 1.14, 95% CI 0.83-1.57); and at Unit A versus Unit B: 24.2% versus 29.2% (aOR 0.73, 95% CI 0.54-0.99). No differences were found in major extensions, or neonatal composite outcome. CONCLUSIONS: Despite the relatively large size of this study, it could not rule out either a positive or a negative association between use of the Fetal Pillow® and uterine extensions, major uterine incision extensions, and neonatal morbidity. Randomised controlled trial evidence is required to assess efficacy.

Placental abruption leading to disseminated intravascular coagulation: a clinical case and short review.

We present the case of a primigravida with disseminated intravascular coagulation at 21 weeks' gestation. Furthermore, we performed a short review of the evidence-based management of the condition. The patient presented with pain and vaginal bleeding. Clinical examination, laboratory studies, and an abdominal ultrasound produced inconclusive results about the origin of her disseminated intravascular coagulation. She was transferred to a tertiary facility where blood and plasma product transfusions were performed, and further investigations revealed fetal demise caused by placental abruption as the underlying cause of her disseminated intravascular coagulation. Cervical preparation was conducted with a balloon catheter and misoprostol. Surgical evacuation of her uterus was performed and she made a full recovery.

Intravenous infusions of ferumoxytol compared to oral ferrous sulfate for the treatment of anemia in pregnancy: a randomized controlled trial.

BACKGROUND: Iron-deficiency anemia in pregnancy is highly prevalent and presents significant risk to patients. Initial treatment is often with oral medication. We hypothesized that intravenous ferumoxytol would result in superior treatment of anemia as compared to oral ferrous sulfate. OBJECTIVE: This study aimed to investigate whether 2 infusions of intravenous ferumoxytol are superior to the use of twice-daily oral ferrous sulfate for the treatment of iron-deficiency anemia in pregnancy. STUDY DESIGN: A randomized controlled trial was performed in which participants with anemic (hemoglobin <11 g/dL and hematocrit <33%) were allocated to receive either 2 infusions of 510 mg of intravenous ferumoxytol approximately 7 days apart, or 325 mg oral ferrous sulfate twice daily from enrollment to the end of their pregnancy. Participants were randomized in a 1:1 ratio to each treatment. Our primary outcome was the change in maternal hemoglobin. Secondary outcomes included maternal iron indices, maternal safety, and maternal tolerability. RESULTS: There were 124 participants (N=62 per group). In the intravenous iron group, the mean change in hemoglobin was 1.86 g/dL (95% confidence interval, 1.57 g/dL-2.14 g/dL) and in the oral group was 0.79 g/dL (95% confidence interval, 0.42 g/dL-1.17 g/dL) (P<.0001). The median change in ferritin between groups was 64.5 (range, 31-364) vs 8 (range, -436 to +167) (P=.0001). The median change in iron between groups was also statistically significant with 47.5 ug/dL (range, -133 ug/dL to +664 ug/dL) in the intravenous group vs 8.5 ug/dL (range, -313 ug/dL to +437 ug/dL) in the oral iron group (P=.001). CONCLUSION: Intravenous ferumoxytol was well tolerated, and it was associated with statistically significant increases in maternal hemoglobin, hematocrit, iron, and ferritin compared to oral ferrous sulfate.

Neonatal outcomes from a randomized controlled trial of maternal treatment of iron deficiency anemia with intravenous ferumoxytol vs oral ferrous sulfate.

BACKGROUND: Anemia in pregnancy is common worldwide and has known maternal risks. The relationship between the types of treatment offered for maternal anemia and the effects on the fetus and newborn are largely uninvestigated. OBJECTIVE: This study aimed to investigate whether maternal treatment with intravenous ferumoxytol compared to oral ferrous sulfate results in an increase in neonatal hematologic and iron indices. These analyses were planned secondary outcomes and post hoc analysis from the trial with a primary outcome of change in maternal hemoglobin. STUDY DESIGN: A randomized controlled trial including 124 participants with anemia by World Health Organization criteria was performed in which participants were allocated in a 1:1 ratio to either 2 infusions of 510 mg of intravenous ferumoxytol or 325 mg oral ferrous sulfate twice daily. Fetal monitoring was performed during each intravenous iron infusion. Standard univariable statistical techniques were used to compare groups and to investigate associations between maternal and neonatal hemoglobin and iron indices. RESULTS: Cord blood hematological parameters were equivalent between groups. Hemoglobin was 15.7 g/dL vs 15.4 g/dL (P=.6) and hematocrit was 50.5% and 49.2% (P=.4) in those randomized to intravenous ferumoxytol and oral ferrous sulfate, respectively. Iron studies revealed higher cord blood ferritin concentrations in infants of participants treated with intravenous ferumoxytol (294 vs 186, P=.005). There were equivalent iron (158 vs 146, P=.4), transferrin (186 vs 196, P=.4) and total iron binding capacity (246 vs 244, P=1) in neonates of participants receiving intravenous vs oral treatment. There were no effects of the infusions observed on cardiotocography. Gestational age at birth was equivalent between groups. We noted a larger birthweight in neonates of participants treated with intravenous ferumoxytol (3215 g vs 3033 g, P=.09), which was not statistically significant. Post hoc analyses revealed a statistically significant correlation between neonatal ferritin and maternal hemoglobin (P=.006) and neonatal ferritin and maternal ferritin (P=.017) at admission for delivery. CONCLUSION: Neonates of participants who received intravenous ferumoxytol were born with higher ferritin concentrations in cord blood, at the same gestation with the same birthweight. Participants with higher hemoglobin and ferritin indices delivered infants with higher ferritin concentrations in cord blood.

Topical negative pressure wound therapy to prevent wound complications following caesarean delivery in high-risk obstetric patients: A randomised controlled trial.

BACKGROUND AND AIMS: We investigated whether the use of a prophylactic negative pressure wound therapy (NPWT) system in women undergoing caesarean would decrease wound complications in a high-risk population. MATERIALS AND METHODS: A randomised controlled trial was performed. Women with risk factors for wound complications undergoing caesarean delivery were randomised to a standard dressing or NPWT placed over their caesarean wound. We standardised the closure of the subcutaneous fat and skin layers, both with Vicryl. Patients were followed for wound complications for up to 6 weeks after their caesareans. The incidence of wound complications was the primary outcome. The single-use NPWT system, PICO, was provided by Smith and Nephew for use in this trial. The trial was registered on clinicaltrials.gov, # NCT03082664. RESULTS: We report here on 154 women randomised to either a standard dressing or to the NPWT. Wound complication rates were equivalent between groups, with 19.4 and 19.7% (P = 0.43) of women with follow-up information available experiencing wound complications. CONCLUSION: We found no difference in wound complications in women with risk factors treated with a prophylactic NPWT system or standard wound dressing at the time of caesarean birth.

High- vs low-dose oxytocin in lean and obese women: a double-blinded randomized controlled trial.

BACKGROUND: Women with obesity are likely to experience longer lengths of labor and are at an increased risk of cesarean delivery. We hypothesized that high-dose oxytocin would decrease the time to delivery in a cohort of women with obesity undergoing induction of labor. OBJECTIVE: This study aimed to assess whether women with obesity benefited from higher doses of oxytocin for induction of labor. STUDY DESIGN: A double-blinded randomized controlled trial was conducted to evaluate the effect of low-dose and high-dose oxytocin on length of labor. We recruited women who were undergoing induction of labor at ≥37 weeks of gestation. Patients were randomly assigned in a 1:1 ratio to receive low-dose or high-dose oxytocin stratified by obesity level (obese and lean). The primary outcome was length of time (minutes) to vaginal delivery. The secondary outcomes included overall cesarean delivery rate, cesarean delivery for labor arrest, maximum oxytocin infusion rate, oxytocin infusion discontinuation, oxytocin infusion decrease, blood loss, neonatal intensive care unit admission, and neonatal Apgar scores. RESULTS: A total of 140 patients were randomized into receiving low-dose and high-dose oxytocin stratified into obese and lean stratum (35 for all strata). The primary outcome, time to vaginal delivery, was similar between the low-dose and high-dose oxytocin groups in the lean stratum (796 [±411] vs 694 [±466] minutes; P=.363) and the stratum with obesity (715 [±497] vs 762 [±594] minutes; P=.733). Kaplan-Meier curves between the low-dose and high-dose oxytocin groups were not significantly different in the lean stratum (P=.391) and the stratum with obesity (P=.692). There were 5 cesarean deliveries (14.29%) in the low-dose oxytocin lean stratum vs 2 cesarean deliveries (5.71%) in the high-dose oxytocin lean stratum (P=.232). There were 4 cesarean deliveries (11.43%) in the low-dose oxytocin stratum with obesity vs 1 cesarean delivery (2.86%) in the high-dose oxytocin stratum with obesity (P=.164). There was no difference in the incidence of postpartum hemorrhage between the lean stratum (P=0.526) and the stratum with obesity (P=0.212). There was no difference in mean estimated blood loss between the lean stratum (P=.472) and the stratum with obesity (P=.215). CONCLUSION: There was no difference in time to delivery between the low-dose and high-dose oxytocin protocols in either the lean cohorts or cohorts with obesity undergoing induction of labor. We did observe a trend toward a lower rate of cesarean delivery in both lean women and women with obesity when high-dose oxytocin was used.

Cervical avulsion during induced labour: diagnosis, intraoperative management and postoperative course.

We report the presentation, operative management and follow-up of a 31-year-old nulliparous woman who experienced a cervical avulsion injury (CAI) during labour. The woman was induced with dinoprostone gel, followed by oxytocin infusion and had a prolonged active phase. During the second stage, fetal decelerations were noted and the consultant asked to make a plan for delivery. When assessing to perform a midpelvic instrumental delivery, a cord of tissue was felt below the fetal head. A caesarean delivery was recommended based on this finding. After delivery, injuries to the broad ligament, posterior lower uterine segment vagina and cervix were repaired. The cervix was retained with the intent that some tissue be salvaged. At 6-week follow-up, transvaginal ultrasound confirmed blood flow in the cervical tissue, though cervical insufficiency was suspected on clinical examination. Our findings reinforce the seriousness of CAI and support conservative surgical management as opposed to trachelectomy or hysterectomy.

Perinatal asphyxia from the obstetric standpoint.

Perinatal asphyxia remains one of the major causes of morbidity and mortality for term newborns. Though access to health care and birth attendants have decreased the rate, Neonatal encephalopathy (NE) has not been eliminated. Worldwide, women at socioeconomic disadvantage have the highest risk of delivering a neonate with NE. Neonates that will experience perinatal asphyxia cannot be easily identified prospectively and the intrapartum testing available is not specific enough to clearly indicate the best course of action in most cases. Despite this, training programs that aim to decrease morbidity and mortality from all causes appear to be associated with fewer cases of perinatal asphyxia. The current best approach is to support education and communication for all people involved in the care of birthing women. Ideally, new technology will address identification of the fetus likely to be affected or the fetus who is beginning to experience injury in advance of delivery.

Cell-Free DNA as an Addition to Ultrasound for Screening of a Complete Hydatidiform Mole and Coexisting Normal Fetus Pregnancy: A Case Report.

Background Complete hydatidiform mole and coexisting normal fetus pregnancies (CHMCF) are rare and can be life-threatening to the mother. Definitive diagnosis can be made with chorionic villus sampling or amniocentesis. However invasive procedures carry a risk of bleeding. We present the case of a twin molar pregnancy where a cell-free DNA screening test was utilized to evaluate for CHMCF pregnancy. Case A patient presented at 15-week gestational age with suspected CHMCF pregnancy. Ultrasound revealed a normal-appearing pregnancy abutting a multicystic lesion concerning for a complete mole. Cell-free DNA was obtained and was suggestive of complete paternal uniparental disomy. Pathological evaluation of the products of conception confirmed the diagnosis of CHMCF. Conclusion In atypical cases, cell-free DNA may be useful in evaluation of molar pregnancy.

A Novel Treatment for Massive Hemorrhage after Maternal Trauma in Pregnancy.

Background Trauma in pregnancy can lead to life-threatening hemorrhage. Conventional treatments of hemorrhage include medical and surgical management. However, if these measures fail uterine compression is an option to control bleeding. We present a case where this management was employed. Case A patient presented at 36 weeks of gestation with multiple injuries after a motor vehicle collision and experienced disseminated intravascular coagulation (DIC). The use of a Bakri balloon in combination with external compression with Coban, a sterile self-adherent bandage, after delivery temporized her bleeding and allowed her to become stable for further management. Conclusion When other measures fail and a hysterectomy is considered unsafe, the combination of internal and external uterine compression is an option.

External Cephalic Version in Cases of Imminent Delivery at Preterm Gestational Ages: A Prospective Series.

Objective When delivery of a breech fetus is required at a preterm gestational age, Cesarean delivery is often recommended. We performed a prospective patient series to assess the success rate and safety of performing external cephalic version (ECV) procedures on preterm fetuses as an alternative to Cesarean delivery. Study Design We performed a prospective clinical series of patients who required delivery with a malpresenting fetus at a preterm gestational age. Results ECV procedures were successful in singletons 50% of the time. No significant complications or cases of fetal mortality were documented. Conclusion ECV at preterm gestational ages may be an appropriate approach to management in patients requiring delivery. Larger series are needed to further document success rates and risks of the procedure.

Misoprostol in Addition to a Double-Balloon Catheter for Induction: A Double-Blind Randomized Controlled Trial.

OBJECTIVE: This article aims to evaluate whether the use of a double-balloon catheter with oral misoprostol results in a lower rate of cesarean and shorter times to delivery than the use of the double-balloon catheter with oral placebo. STUDY DESIGN: In a double-blind randomized controlled trial, a double-balloon catheter was used for induction of labor with two doses of either 50 µg of misoprostol or placebo. Outcomes included cesarean rate, time to vaginal delivery, change in Bishop's score, and oxytocin usage. RESULTS: A total of 343 women were screened and 199 randomized: 99 to the misoprostol arm and 100 to the placebo arm. Cesarean delivery rate was not different between the groups (misoprostol: 13.1% vs. placebo: 17.0%, p = 0.45). Time to vaginal delivery was significantly shorter (mean: 14.6 ± 6.9 vs. 20.8 ± 13.8 hours, p < 0.0001), change in Bishop's score was significantly greater (median: 5 vs. 4 points, p = 0.005), and use of oxytocin was significantly less frequent (86.9 vs. 98.0% patients, p = 0.01) in the misoprostol group. CONCLUSION: The use of a double-balloon catheter with oral misoprostol for induction did not reduce the cesarean delivery rate, but did result in shorter labors, a greater increase in Bishop's score, and a lower need for oxytocin use.

Does Maternal Body Mass Index Have an Effect on the Accuracy of Ultrasound-Derived Estimated Birth Weight?: A Retrospective Study.

OBJECTIVES: The purpose of this study was to investigate the relationship between the maternal body mass index (BMI) and the accuracy of ultrasound-derived birth weight. METHODS: A retrospective chart review was performed on women who had an ultrasound examination between 36 and 43 weeks' gestation and had complete delivery data available through electronic medical records. The ultrasound-derived fetal weight was adjusted by 30 g per day of gestation that elapsed between the ultrasound examination and delivery to arrive at the predicted birth weight. RESULTS: A total of 403 pregnant women met inclusion criteria. Age ranged from 13-44 years (mean ± SD, 28.38 ± 5.97 years). The mean BMI was 32.62 ± 8.59 kg/m2 . Most of the women did not have diabetes (n = 300 [74.0%]). The sample was primarily white (n = 165 [40.9%]) and Hispanic (n = 147 [36.5%]). The predicted weight of neonates at delivery (3677.07 ± 540.51 g) was higher than the actual birth weight (3335.92 ± 585.46 g). Based on regression analyses, as the BMI increased, so did the predicted weight (P < .01) and weight at delivery (P < .01). The accuracy of the estimated ultrasound-derived birth weight was not predicted by the maternal BMI (P = .22). Maternal race and diabetes status were not associated with the accuracy of ultrasound in predicting birth weight. CONCLUSIONS: Both predicted and actual birth weight increased as the BMI increased. However, the BMI did not affect the accuracy of the estimated ultrasound-derived birth weight. Maternal race and diabetes status did not influence the accuracy of the ultrasound-derived predicted birth weight.

Shoulder dystocia: prediction and management.

Shoulder dystocia is a complication of vaginal delivery and the primary factor associated with brachial plexus injury. In this review, we discuss the risk factors for shoulder dystocia and propose a framework for the prediction and prevention of the complication. A recommended approach to management when shoulder dystocia occurs is outlined, with review of the maneuvers used to relieve the obstruction with minimal risk of fetal and maternal injury.

Screening for Chlamydia and Gonorrhea Cervicitis and Implications for Pregnancy Outcome. Are We Testing and Treating at the Right Time?

OBJECTIVE: To evaluate the effect of gonorrheal and chlamydial cervicitis (GCC) on the risk of preterm labor (PTL) and preterm premature rupture of membranes (PPROM). STUDY DESIGN: A large cross-sectional sample of patients (N = 1,120) was studied. Data on samples for GCC and pregnancy outcome were entered into a database from a retrospective chart review. RESULTS: There were 1,120 pregnancies with adequate data for analysis. Of those pregnancies 933 were unaffected by GCC, and 187 were affected. The rates of preterm delivery were 17.79% and 16.58% for GCC-negative and GCC-positive pregnancies, respectively. PPROM occurred in 3.97% and 2.67% of GCC-negative and GCC-positive pregnancies, respectively. PTL occurred in 8.25% and 8.02% of GCC-negative and GCC-positive pregnancies, respectively. No outcomes met statistical significance. When pregnancy outcomes were analyzed by trimester of infection, there was a higher risk of preterm delivery but not preterm labor with earlier infection. This did meet statistical significance. There was a trend towards lower rate of cesarean section in the infected group of patients, which did not meet statistical significance. CONCLUSION: Maternal infection with gonorrhea and/or chlamydia is not associated with PPROM or PTL.

Intrauterine Treatment of a Fetus with Familial Hypertrophic Cardiomyopathy Secondary to MYH7 Mutation.

There is no clear consensus on optimal management of fetuses affected by familial hypertrophic cardiomyopathy (HCM). Intrauterine treatment of the condition has not been attempted in any standardized fashion. We report the case of a fetus treated by maternal propranolol during the third trimester after septal hypertrophy and diastolic dysfunction was diagnosed on fetal echocardiogram. The pregnancy went successfully to term, and fetal septal hypertrophy was noted to improve prior to delivery.