STRAWB2 (Stress and Wellbeing After Childbirth): a randomised controlled trial of targeted self-help materials to prevent post-traumatic stress disorder following childbirth.

OBJECTIVES: To test whether providing psychological self-help materials would significantly lower the incidence of post-traumatic stress disorder (PTSD) at 6-12 weeks postnatally. DESIGN: Open-label randomised controlled trial, with blinded outcome assessment. SETTING: Community midwifery services in two National Health Service (NHS) trusts in the North West. SAMPLE: A cohort of 2419 women receiving normal NHS postnatal care. METHODS: Midwives screened women for traumatic birth experience; 678 women who screened positively (28.1%) were randomly allocated to self-help with usual care (n = 336) or to usual care alone (n = 342). The self-help materials were a leaflet and online film designed to prevent the development of PTSD after trauma exposure through explaining how to manage early psychological responses. MAIN OUTCOME MEASURE: The primary outcome was a composite of diagnostic and subdiagnostic PTSD at 6-12 weeks postnatally using the gold-standard Clinician-Administered PTSD Scale (CAPS-5) interview. RESULTS: Of the 678 women correctly randomised plus the nine women randomised in error, 478 (70.5%) were followed up. Diagnostic or subdiagnostic PTSD rates at follow-up did not differ between groups who received self-help (26.7%, 65/243) or usual care alone (26.2%, 64/244) (intention-to-treat analysis: RR 1.02, 95% CI 0.68-1.53). Findings remained consistent in the per-protocol analysis (RR 1.04, 95% CI 0.85-1.27). Women viewed the materials very positively. There were no adverse effects. Health economic micro-costing indicated implementation would be very low cost. CONCLUSIONS: Many women experience a traumatic birth and risk developing PTSD, but self-help strategies without professional support are insufficient and should not be routinely introduced. TWEETABLE ABSTRACT: Self-help information alone does not reduce the number of women developing PTSD after a traumatic childbirth.

Who tells a mother her baby has died? Communication and staff presence during stillbirth delivery and early infant death.

OBJECTIVE: Perinatal loss (stillbirth or early infant death) is often a sudden, unexpected event for families. We evaluated who communicates the loss to the parents and who is there for support at the delivery or death. STUDY DESIGN: We conducted a mail survey of 900 bereaved and 500 live-birth mothers to assess emotional, physical and reproductive health outcomes. RESULTS: We had a 44% response rate at 9 months after birth or loss from 377 bereaved mothers and 232 with surviving infants. Bereaved women were less likely to have hospital staff or family members present at delivery. African-American (versus Caucasian) mothers were half as likely to have first heard about their stillbirth from a physician or midwife. CONCLUSION: This is the first large study documenting who communicates perinatal death to families and who is present for support. Hospitals should be aware that many bereaved families may lack support at critical times.

Maternal complications associated with stillbirth delivery: A cross-sectional analysis.

This study sought to identify delivery complications associated with stillbirth labour and delivery. We conducted a retrospective chart review evaluating stillbirth demographics, pregnancy and maternal risk factors, and complications of labour and delivery. We performed bivariable analysis and multivariable logistic regression to evaluate factors associated with medical complications and variations by race. Our cohort included 543 mothers with stillbirth, of which two-thirds were African-American. We noted high rates of shoulder dystocia, clinical chorioamnionitis, postpartum haemorrhage and retained placenta in women with stillbirths. Thirty-three women (6%) experienced at least one serious maternal complication. Complication rates did not vary by maternal race. Providers who perform obstetrical care should be alert to the high rate of maternal medical complications associated with labour and delivery of a stillbirth foetus.

An expanded Transactional Stress and Coping Model for siblings of children with sickle cell disease: family functioning and sibling coping, self-efficacy and perceived social support.

AIM: To investigate the application of an expanded Transactional Stress and Coping Model for the psychological adjustment of non-chronically ill, African-American siblings of children with sickle cell disease (SCD). METHODS: Ninety-seven siblings (M = 11.24 years) from 65 families who care for a child with SCD participated. Primary caregivers completed the Coping Health Inventory for Parents, the Family Relations Scale and the Child Behaviour Checklist, while siblings completed the Kidcope, the Children's Self-Efficacy for Peer Interaction Scale, and the Social Support Scale for Children. RESULTS: Family processes were predictive of sibling adjustment, revealing that family coping, expressiveness and support improved adjustment, while family conflict predicted poor adjustment. CONCLUSION: Findings suggest that family-centered interventions stressing family expressiveness and support, while minimizing conflict, will contribute to sibling psychological adjustment.

Middle cerebral artery peak systolic velocity: a new Doppler parameter in the assessment of growth-restricted fetuses.

OBJECTIVE: The aims of this study were to determine if there is a relationship between middle cerebral artery (MCA) peak systolic velocity (PSV) and perinatal mortality in preterm intrauterine growth-restricted (IUGR) fetuses, to compare the performance of MCA pulsatility index (PI), MCA-PSV and umbilical artery (UA) absent/reversed end-diastolic velocity (ARED) in predicting perinatal mortality, to determine the longitudinal changes that occur in MCA-PI and MCA-PSV in these fetuses, and to test the hypothesis that MCA-PSV can provide additional information on the prognosis of hypoxemic IUGR fetuses. METHODS: This was a retrospective cross-sectional study of 30 IUGR fetuses (estimated fetal weight < 3(rd) percentile; UA-PI > 95% CI) in which the last MCA-PI, MCA-PSV and UA values were obtained within 8 days before delivery or fetal demise. Among the 30 fetuses, there were 10 in which at least three consecutive measurements were performed before delivery and these were used for a longitudinal study. MCA-PSV and MCA-PI values were plotted against normal reference ranges and were considered abnormal when they were above the MCA-PSV or below the MCA-PI reference ranges. RESULTS: Gestational age at delivery ranged between 23 + 1 and 32 + 5 (median, 27 + 6) gestational weeks. Birth weight ranged from 282 to 1440 (median, 540) g. There were 11 perinatal deaths. Forward stepwise logistic regression indicated that MCA-PSV was the best parameter in the prediction of perinatal mortality (odds ratio, 14; 95% CI, 1.4-130; P < 0.05) (Nagerlke R(2) = 31). In the 10 fetuses studied longitudinally, an abnormal MCA-PI preceded the appearance of an abnormal MCA-PSV. In these fetuses, the MCA-PSV consistently showed an initial increase in velocity; before demise or the appearance of a non-reassuring test in seven fetuses, there was a decrease in blood velocity. The MCA-PI presented an inconsistent pattern. CONCLUSIONS: In IUGR fetuses, the trends of the MCA-PI and MCA-PSV provide more clinical information than does one single measurement. A high MCA-PSV predicts perinatal mortality better than does a low MCA-PI. We propose that MCA-PSV might be valuable in the clinical assessment of IUGR fetuses that have abnormal UA Doppler.

Three-dimensional ultrasound in the prenatal diagnosis of cleidocranial dysplasia associated with B-cell immunodeficiency.

A patient with a singleton pregnancy was referred for three-dimensional ultrasonography (3DUS) at 18 + 3 weeks for suspected hypomineralization of the skull bones and absence of the nasal bones. Three-dimensional rendered images of the fetal skull revealed widening of the coronal sutures, absence of the squamous portion of the temporal bone, and absence of the occipital bone, except for two areas of ossification. In addition, a fractured right clavicle was identified. The remainder of the fetal anatomy was normal and biometry was appropriate for gestational age. Genetic amniocentesis revealed a 46,XX fetal karyotype. Family history was positive for a 5-year-old sibling with an open anterior fontanelle. Cleidocranial dysplasia was suspected. A female neonate was delivered by elective repeat Cesarean section at 40 + 3 weeks of gestation without complications and discharged home 3 days after delivery. Prenatal diagnosis was confirmed by physical and radiological evaluation. The infant died at 8 weeks of age due to respiratory syncytial virus pneumonia secondary to B-cell deficiency. RUNX2 mutations were not detected by molecular analysis. There are three relevant aspects to this case: (1) clear visualization of the widened fontanelles and hypomineralized occipital bones was possible with the use of 3DUS; (2) a clavicular fracture was identified in utero with combined high-resolution two-dimensional and 3DUS; and (3) although absence of the nasal bones is most commonly observed in fetuses with chromosomal disorders (e.g. trisomy 21 and trisomy 18), a careful examination of the skeleton should be considered in fetuses with absent nasal bones and a normal karyotype.

Fetal cardiac dysfunction in preterm premature rupture of membranes.

BACKGROUND: Preterm premature rupture of membranes (PROM) is associated with one-third of preterm births. In about 50% of preterm PROM cases, the fetuses will elicit a fetal inflammatory response syndrome (FIRS). FIRS is associated with the impending onset of preterm labor, periventricular leukomalacia, neonatal sepsis, and long-term handicap, including the development of bronchopulmonary dysplasia and cerebral palsy. The fetal myocardium is a potential target organ of proinflammatory cytokines released during FIRS. The objective of this study was to determine whether preterm PROM is associated with functional changes in the fetal heart, as determined by fetal echocardiography. METHODS: A retrospective study was conducted to assess the diastolic function of fetuses with preterm PROM with documented microbial invasion of the amniotic cavity (n = 25), preterm PROM without microbial invasion of the amniotic cavity (n = 42), and fetuses from normal pregnancies (control group = 150). Pregnancies with multiple gestation, fetal distress, fetuses that were small for gestational age, and major congenital anomalies were excluded. Fetal echocardiography studies were performed with two-dimensional ultrasound, color Doppler imaging and pulsed Doppler ultrasound. Non-parametric statistics were used for comparisons. A p value of < 0.05 was considered significant. RESULTS: The prevalence of positive amniotic fluid cultures for micro-organisms in patients with preterm PROM was 35.8% (24/67). Ureaplasma urealyticum was the most frequent isolate, either alone (41.7%; 10/24) or with other micro-organisms (29.2%; 7/24). Fetuses with preterm PROM had a higher delta early diastolic filling/atrial contraction (E/A) peak velocity ratio, a higher delta E/A velocity-time integral (VTI) ratio, a lower delta A peak velocity, a lower delta A VTI, and a lower A VTI/total VTI ratio in the mitral valve compared to those with uncomplicated pregnancies. The delta E/A peak velocity ratio was significantly higher and the delta A VTI significantly lower in fetuses with preterm PROM and microbial invasion of the amniotic cavity than in those with preterm PROM without microbial invasion of the amniotic cavity. CONCLUSIONS: Preterm PROM is associated with changes in fetal cardiac function consistent with increased left ventricular compliance. These observations were also noted in fetuses with microbial invasion of the amniotic cavity. Our findings suggest that fetal cardiac function is altered in preterm PROM and, in particular, in cases with intra-amniotic infection.

Prenatal diagnosis of membranous ventricular septal aneurysms and their association with absence of atrioventricular valve 'offsetting'.

Congenital aneurysm of the membranous portion of the ventricular septum in association with absence of atrioventricular valve 'offsetting' was diagnosed in two fetuses at 29 and 34 weeks. In the first case the fetus had a normal karyotype and no other structural heart defects, whereas in the second case there was a partial deletion of the long arm of chromosome 5 and an absent pulmonary valve syndrome. The association of absence of 'offsetting' with aneurysms of the membranous ventricular septum may represent spontaneous closure of ventricular septal defects initially extended to the inlet.

The impact of maternal obesity on midtrimester sonographic visualization of fetal cardiac and craniospinal structures.

OBJECTIVE: To examine the impact of maternal obesity on the rate of suboptimal ultrasound visualization (SUV) of fetal anatomy and determine the optimal timing of prenatal ultrasound examination for the obese gravida. METHODS: A computerized ultrasound database was used to identify ultrasound examinations for singleton gestations performed between 14(0/7) and 23(6/7) weeks at a tertiary care, university-based hospital. Patients were divided into four groups and categorized based on body mass index (BMI): nonobese (BMI <30 kg/m2), class I obesity (30< or =BMI<35 kg/m2), class II obesity (35< or =BMI<40 kg/m2), and extreme obesity (BMI > or =40 kg/m2). The rates of SUV for fetal cardiac and craniospinal structures were calculated for each group and compared. RESULTS: A total of 11,019 pregnancies were studied, of which 38.6% of the patients were obese. Overall, the rate of SUV of the fetal structures was higher for obese compared to nonobese women for both cardiac (37.3 [1723/4200] vs 18.7% [1275/6819]; P<0.0001) and craniospinal structures (42.8 [1798/4200] vs 29.5% [2012/6819]; P<0.0001). Increased severity of maternal obesity was associated with SUV rate for both the cardiac (nonobese 18.7% [1275/6819], class I 29.6% [599/2022], class II 39.0% [472/1123], and extreme obesity 49.3% [580/1055]; P<0.0001) and for the craniospinal structures: (nonobese 29.5% [2012/6819], class I 36.8% [744/2022], class II 43.3% [486/1123], and extreme obesity 53.4% [563/1055]; P<0.0001). With increasing gestational age at examination, the rate of SUV decreased for both obese and nonobese women. However, for obese women there was minimal improvement in visualization after 18-20 weeks. Even after adjustment for gestational age and the type of ultrasound machine, obese women (class I, class II, and extreme obesity) were still associated with increased odds for SUV of the fetal cardiac and craniospinal structures compared to nonobese women. CONCLUSION: Maternal obesity increases the rate of SUV for the fetal cardiac structures by 49.8% and for the craniospinal structures by 31%. The optimal gestational age for visualization of fetal cardiac and craniospinal anatomy in obese patients may be after 18-20 weeks.

Three-dimensional ultrasound fetal lung volume measurement: a systematic study comparing the multiplanar method with the rotational (VOCAL) technique.

OBJECTIVES: This study was designed to compare a conventional multiplanar technique for three-dimensional (3D) ultrasound measurement of fetal lung volume with a rotational method using VOCAL trade mark (Virtual Organ Computer-aided AnaLysis). METHODS: Thirty-two fetuses with a variety of conditions at risk for pulmonary hypoplasia were studied. 3D volume data sets of the fetal lungs were acquired using a commercially available ultrasound system. The right and left lung volumes were calculated separately using VOCAL and the multiplanar technique. The level of agreement between two independent observers in categorizing the 3D volume data set as measurable or non-measurable was determined. The interobserver and intermethod variabilities were also evaluated for both methods. RESULTS: The intermethod variability was excellent (correlation r = 0.93 and r = 0.96 for the left and right lung, respectively), and there was substantial agreement between the results of both approaches (limits of agreement - 4.4 to 8.9 and - 3.4 to 4.8 mL for the right and left lung, respectively). Fetal lung estimation with VOCAL had a significantly higher interobserver variability than the multiplanar technique. Interobserver agreement in categorizing lung volume data sets as measurable or non-measurable was lower when VOCAL was used. CONCLUSION: Fetal lung volume measurements can be undertaken interchangeably using the multiplanar technique or the rotational method with VOCAL. However, the latter was less reproducible (lower degree of agreement and significantly higher interobserver variability) than the former.

Effects of intrapartum zidovudine therapy on fetal heart rate parameters in women with human immunodeficiency virus infection.

OBJECTIVE: To determine the effects of intrapartum maternal administration of zidovudine on fetal heart rate (FHR) parameters in women infected with the human immunodeficiency virus (HIV). METHODS: Term HIV-infected women who delivered at our institution (1995-1998) were identified by medical records coding. Sixty minutes of FHR tracing prior to zidovudine administration and 60 min of FHR tracing 2 h after initiation of therapy were reviewed by 3 perinatologists blinded to patient status. Data were compared with paired t tests; p < 0.05 was considered significant. Inter- and intra-observer FHR interpretation variation were calculated. RESULTS: Ten patients met study criteria. Their demographic data included: Maternal age 26.5 +/- 6.5 years, gestational age 38.9 +/- 1.3 weeks, median parity 2 (range 0-3). Eighty percent were African American. There were no significant differences in FHR parameters after intravenous zidovudine therapy (pretreatment versus 2 h after treatment) with respect to FHR baseline (p = 0.2), FHR variability (p = 0.3), or the number of accelerations (p = 0.1). There was also no difference in the number of variable (moderate or severe), early, or prolonged decelerations following zidovudine infusion. CONCLUSION: Two hours of continuous intrapartum intravenous infusion of zidovudine does not alter any parameter of the FHR in the laboring HIV-infected gravida.

A pilot study of time allocation and reimbursement for routine obstetric ultrasonography.

OBJECTIVE: To evaluate time allocation during initial and repeated ultrasonography and to formulate recommendations to improve unit efficiency. METHODS: Over a 2-year period, 51 comprehensive ultrasonographic examinations between 14 and 38 weeks' gestational age were observed by a single reviewer. Each patient-sonographer interaction was divided into timed segments, including setup, examination time, review, and turnover. Statistical analysis using descriptive statistics, Student ttest, and analysis of variance was performed to determine the effect of the number of ultrasonographic examinations, sonographer experience, estimated gestational age, and patient body mass index on examination time. RESULTS: The average time spent with each patient was 15 minutes 22 seconds: 2 minutes 10 seconds for setup, 9 minutes 38 seconds for examination, 1 minute 50 seconds for review, and 1 minute 44 seconds for turnover. Examination length was not significantly affected by estimated gestational age, body mass index, ultrasonography experience, or the number of ultrasonographic examinations (P > .05). No statistical significance in the duration of scanning was found between initial (15 minutes 3 seconds) and repeated (16 minutes 1 second) examinations (P = .609). Nonexamination activities, such as data entry and room cleanup, consumed 37% of the sonographer's time. CONCLUSIONS: Resource use within the ultrasonography department may be improved by reassigning clerical and custodial duties from sonographers to other personnel. Although differential reimbursement exists, no statistically significant difference in resource use between initial and repeated examinations was found.

Does cervical cerclage prevent preterm delivery in patients with a short cervix?

OBJECTIVE: Our purpose was to determine whether cerclage placement in women with a short cervix on transvaginal ultrasonography reduces the rate of preterm delivery. STUDY DESIGN: A retrospective cohort study identified patients with an ultrasonographic short cervix (cervical length < or =15 mm) between 14 and 24 weeks' gestation. Cerclage placement was performed at the discretion of the attending physician. Clinical characteristics and outcome with and without cerclage were compared. RESULTS: Seventy patients met inclusion criteria; 25 (36%) underwent cerclage placement. Patients managed with cerclage had a lower gestational age at diagnosis (19.6 weeks vs 21.3 weeks, P <.01) but had a similar median cervical length, presence of funneling, and a history of cervical surgery, in comparison with those managed without cerclage. The rate of spontaneous preterm delivery was not different between groups. Patients with cerclage had a higher rate of preterm premature rupture of membranes than those without cerclage (65.2% vs 36.4%, P <.05). CONCLUSION: Cervical cerclage in patients with a short cervix did not reduce the rate of spontaneous preterm delivery and increased the risk of preterm premature rupture of membranes.

First-trimester embryo size discordance: a predictor of premature birth following multifetal pregnancy reduction.

OBJECTIVE: We have previously reported a correlation between the starting number of embryos for multifetal pregnancy reduction (MFPR) and discordance in size during the first trimester. Here we evaluated the correlation between the degree of discordance and length of gestation in the remaining fetuses. DESIGN: Observational clinical series. SETTING: Academic medical center with a single physician who performs a large number of MFPRs. PATIENT(S): Analysis of 252 consecutive MFPRs from a 2.5-year period (1996-1998). INTERVENTION(S): MFPR for patients with multifetal pregnancies. MAIN OUTCOME MEASURE(S): We evaluated the correlation between the degree of discordance in embryo size, as measured by the greatest difference in crown-rump length (CRL) (delta max), and the length of gestation. RESULT(S): Embryo size discordance was related to length of gestation of the remaining fetuses after MFPR. Of 72 patients with a delta max >5 mm, the rate of severe premature birth (delivery at <28 weeks' gestation) was 9.7%, compared with 1.7% for patients with a delta max <5 mm (P<.01). Of patients with severe premature birth, 70% had delta max >5 mm, compared with less than 30% in patients who delivered after 28 weeks (P<.05). CONCLUSION(S): Variations in embryo growth patterns in multifetal pregnancies may be observed even in the first trimester, which may be predictive of late pregnancy outcomes. With a delta max > or =5 mm, there is a significant increase in the risk of severe premature birth (delivery at <28 weeks).

Improving adherence with deferoxamine regimens for patients receiving chronic transfusion therapy.

We designed a study to obtain follow-up on behavioral aspects of compliance with home deferoxamine administration, explore social factors that might influence compliance, and evaluate the effectiveness of a pilot intervention program for patients with thalassemia or sickle cell disease who were receiving chronic transfusion therapy. Thirty-one patients between the ages of 6 and 21 years and their primary caregivers were administered a 24-hour recall Interview about home care. Fifteen went on to participate in a Desferal Day Camp, which combined educational strategies with peer support. Behavioral measures of treatment adherence were similar for most patients with sickle cell disease and thalassemia. Patient compliance with days of deferoxamine administration at follow-up was associated with initial compliance, perceived support, and patient and caregiver knowledge. Increased sharing of responsibilities for home care by patients and caregivers and caregiver knowledge were associated with lower ferritin and liver iron levels. A subsample of 3 patients who were extremely noncompliant with days of deferoxamine administration was examined separately; these patients were found to be moderately compliant with the number of hours and amount of deferoxamine administered and to share fewer home care tasks with primary caregivers. Participation in Desferal Day Camp did not result in increases in knowledge or peer support, suggesting that future interventions should focus on family support and on improving self-regulatory skills. The crucial role of collaboration among patients, families, and health care providers in developing interventions to enhance adherence was emphasized.

Patients with an ultrasonographic cervical length < or =15 mm have nearly a 50% risk of early spontaneous preterm delivery.

OBJECTIVE: The aim of this study was to determine the value in the prediction of spontaneous preterm delivery of ultrasonographically measured cervical length measured between 14 and 24 weeks' gestation. STUDY DESIGN: A retrospective cohort study examined cervical length by means of a two-stage procedure, transabdominal ultrasonography followed by transvaginal ultrasonography if cervical length was <30 mm. RESULTS: A total of 6877 patients met inclusion criteria. Mean cervical length was 37.5 mm. Odds ratios for early preterm delivery (< or =32 weeks' gestation) for patients with cervical lengths < or =10, < or =15, < or = 20, < or =25, and < or =30 mm were, respectively, 29.3 (95% confidence interval, 11.3-75.8), 24.3 (95% confidence interval, 12. 9-45.9), 18.3 (95% confidence interval, 10.8-31.0), 13.4 (95% confidence interval, 8.8-20.6), and 3.2 (95% confidence interval, 2. 4-4.4). For early preterm delivery a cervical length of < or =15 mm had a positive predictive value of 47.6%, a negative predictive value of 96.7%, a sensitivity of 8.2%, and a specificity of 99.7%. CONCLUSIONS: A short cervix seen on a second-trimester sonogram was a powerful predictor of early spontaneous preterm delivery (< or =32 weeks' gestation). Nearly 50% of patients with a cervical length < or =15 mm had an early spontaneous preterm delivery, which suggests that clinical trials of interventions (eg, cerclage) in this population are urgently needed.

Benefits associated with harmonic tissue imaging in the obstetric patient.

OBJECTIVE: We sought to determine the impact of harmonic tissue imaging on image resolution and visualization of fetal structures during obstetric ultrasonography. STUDY DESIGN: Patients with singleton second- or third-trimester fetuses were recruited. Prospective comparisons of conventional fundamental imaging and harmonic tissue imaging were made. Visualization rates and frequencies of improvement in resolution were calculated. Discriminate function analysis evaluated determinants of improved visualization. RESULTS: Harmonic tissue imaging improved resolution of at least one fetal structure in 51.4% of patients studied. Differences were most marked for 4-chamber views of the heart with improvement in resolution in 30.5% of patients and change in ability to visualize in 9.5%. Maternal weight and gestational age had a significant influence on whether improvements were noted with harmonic tissue imaging, accounting for 27% of the variance. CONCLUSIONS: Harmonic tissue imaging offers significant improvements over fundamental imaging in image resolution and structure visualization in obese patients during the second trimester of pregnancy.