Screening options for Down syndrome: how women choose in real clinical setting.

OBJECTIVE: To study pregnant women's preference among various screening options for Down syndrome (DS) in routine clinical setting, and its potential association with women's demographic characteristics. METHODS: Women aged 35 years and older carrying singleton pregnancy were offered a variety of screening tests for DS before 14 weeks of gestation. Their preference was confirmed by the test they actually underwent. The association between women's choice of test and a number of demographic characteristics was studied using multinomial regression. RESULTS: Among 1967 eligible women, 619 opted for first-trimester screening test (FTS), 924 for partial integrated test (PIT), and 424 for full integrated test (FIT). Nulliparous women and working mothers were more likely to choose FTS and FIT. Women with history of subfertility were more likely to choose FIT. Women with family history of chromosomal abnormalities were more likely to choose FTS. The choice of screening test could be predicted for 49.9% of women using four demographic characteristics. CONCLUSIONS: Among older women of predominantly Chinese ethnicity, integrated test is a favorite alternative to FTS. Their choice of DS screening test can be predicted by their obstetric and socioeconomic characteristics. Many women show willingness to pay for a test with a lower false-positive rate.

Conservative management of placenta praevia with accreta.

It has been advocated that placenta accreta/percreta should be managed conservatively to avoid massive pelvic bleeding and preserve fertility. Diagnosis of this condition with high-resolution imaging investigations performed during the antenatal period facilitates discussion of management plans with other clinical disciplines (eg interventional radiologists), the patient, and her family. Three cases of placenta praevia with accreta are presented. The three cases were managed by leaving the placenta in-utero after caesarean section, using uterine arterial embolisation to control postpartum haemorrhage only when needed. In all these cases, we succeeded in conserving the uterus without major complications. With improved imaging techniques, accurate antenatal diagnosis of placenta praevia with accreta is now possible. This new approach to conservative management can be considered in order to not only conserve the uterus but also to avoid uncontrolled pelvic haemorrhaging.

Effect of fetal diagnosis on the outcomes of second-trimester pregnancy termination for fetal abnormalities: a pilot study.

OBJECTIVE: To explore whether the outcomes of second-trimester pregnancy termination for fetal abnormalities are affected by fetal diagnoses. METHODS: This was a retrospective review of cases undergoing second-trimester pregnancy termination for the fetal diagnoses of hemoglobin Barts, trisomy 21, and trisomy 18 during the period from 1999 to 2006. The affected pregnancies were terminated by vaginal misoprostol. The outcome measures were: (1) abortion within 24 hours after misoprostol commencement, (2) histology-confirmed incomplete abortion, and (3) experience of significant side effects during termination (temperature over 39 degrees C or need for metoclopramide for vomiting). RESULTS: One hundred and twenty cases were available for analysis. After adjusting for maternal age, parity, history of cesarean delivery, body mass index, gestation, and fetal hydrops, pregnancy termination for trisomy 21 was associated with a higher risk of incomplete abortion than trisomy 18 and hemoglobin Barts (odds ratio 5.25, 95% confidence interval 1.24-22.19, p = 0.024). The chance of abortion within 24 hours and experience of significant side effects were not found to be associated with fetal diagnosis. CONCLUSIONS: Pregnancy termination for trisomy 21 is associated with a higher risk of incomplete abortion. Fetal diagnosis affects the outcome of pregnancy termination.

Reversed diastolic flow in the uterine artery - a new Doppler finding related to placental insufficiency?

Increased uterine artery pulsatility and resistance indices with or without notching of the waveform have been associated with an increased risk of pre-eclampsia and fetal growth restriction. However, reversed diastolic flow in the uterine artery has not previously been reported. We present two high-risk obstetric cases complicated by severe placental insufficiency: pre-eclampsia followed by eclampsia in one case and intrauterine growth restriction with abnormal cardiotocography in the other. Doppler studies of the uterine arteries revealed reversed diastolic flow in both cases. The pathophysiology and potential implications are discussed.

Unexpected reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries during the study period: was this the Hawthorne effect?

OBJECTIVE: The study was originally designed to identify the risk factors that could predict those difficult instrumental deliveries resulting in birth trauma and birth asphyxia. DESIGN: A prospective study on all singleton deliveries in cephalic presentation with an attempt of instrumental delivery over a 12-month period (13 March 2000 to 12 March 2001). SETTING: A local teaching hospital. SAMPLE: Six hundred and seventy deliveries. METHODS: A codesheet was designed to record the demographic data, characteristics of first and second stages of labour and neonatal outcome. In particular, the doctor had to enter the pelvic examination findings before the attempt of instrumental delivery. MAIN OUTCOME MEASURES: Birth trauma and birth asphyxia. RESULTS: There was a significant reduction in the incidence of birth trauma and birth asphyxia related to instrumental deliveries during the study period (0.6%) when compared with that (2.8%) in the pre-study period (1998 and 1999) (RR 0.27, 95% CI 0.11-0.70). There was more trial of instrumental deliveries in the operating theatre although this was not statistically significant (RR 1.19, 95% CI 0.88-1.60). The instrumental delivery rate decreased during the study period (RR 0.88, 95% CI 0.82-0.94). The caesarean section rate for no progress of labour, the incidence of direct second stage caesarean section and the incidence of failed instrumental delivery did not increase during the study period. CONCLUSIONS: Apart from the merits of regular audit exercise and increasing experience of the staff, the Hawthorne effect might be the major contributing factor in the reduction of birth trauma and birth asphyxia related to instrumental deliveries during the study period.

Factors affecting outcomes of prenatally-diagnosed tumours.

OBJECTIVE: The outcomes of prenatally-diagnosed tumours affect obstetrical management and parental decisions. The present study reviews the factors affecting outcomes for fetuses with prenatally-diagnosed tumours. METHODS: Medical records of all fetuses referred to our institutions with antenatally-diagnosed tumours were reviewed for the type and location of the tumours, results of treatment and/or causes of death. RESULTS: From January 1994 to May 2001, there were 15 fetuses with antenatally- diagnosed tumours: mesoblastic nephroma (MN) (n=2); neuroblastoma (NB) (n=2); cystic hygroma (CH) (n=3); intracranial germ cell tumour (IGCT) (n=2); sacrococcygeal teratoma (SCT) (n=3) and haemangioma (liver, n=2; limb, n=1). One mother had termination of pregnancy for her fetal SCT. Three mothers had Caesarean section for large fetal heads (CH, n=2; IGCT, n=1). Three fetuses died; two with IGCT and one with SCT, who died of heart failure. Two newborns with CH needed emergency intubation and, later, one of them had tracheostomy. One baby had cardiac failure resulting from a lower limb haemangioma and needed drug therapy. All solid tumours (MN, NB, SCT) of the live births had no recurrence after surgery with or without adjuvant chemotherapy. CONCLUSION: Prenatally-diagnosed tumours without any other associated abnormality cause morbidity and mortality because of their location and vascularity. Solid tumours are relatively benign.