The Challenges of Distinguishing Different Causes of TMA in a Pregnant Kidney Transplant Recipient.

Thrombotic microangiopathy (TMA) reflects a syndrome of endothelial injury characterised by microangiopathic haemolytic anaemia (nonimmune), thrombocytopenia, and often end-organ dysfunction. TMA disorders are well-recognised in kidney transplant recipients, often due to an underlying genetic predisposition related to complement dysregulation, or de novo due to infection, immunosuppression toxicity, or antibody-mediated rejection. In pregnancy, TMA disorders are most commonly due to severe pre-eclampsia or HELLP, but may also be due to thrombotic thrombocytopenic purpura (TTP) or complement-mediated (atypical) haemolytic uremic syndrome (aHUS). Complement dysregulation is being recognised as playing a role in the development of preeclampsia and HELLP syndrome in addition to aHUS. Due to overlapping clinical and laboratory features, diagnosis can be difficult and delays in treatment can be life-threatening for both mother and fetus. This report describes a 32 year-old female who had two successive wanted pregnancies. The first pregnancy was terminated at 22 weeks gestation due to presumed severe preeclampsia and fetal growth restriction in the context of known chronic kidney failure due to reflux nephropathy. A living-related kidney transplant was performed to improve the chances of pregnancy resulting in a live birth. A subsequent pregnancy was complicated by progressive kidney impairment and hypertension at 22 weeks gestation. Kidney biopsy showed TMA, but the etiology was unclear. This report highlights the diagnostic dilemma of TMA in a pregnant kidney transplant recipient and a role for the anti-C5 terminal complement blockade monoclonal antibody eculizumab, in pregnancy-associated TMA, especially at a peri-viable gestation.

STRIDER NZAus: a multicentre randomised controlled trial of sildenafil therapy in early-onset fetal growth restriction.

OBJECTIVE: To assess the effect of maternal sildenafil therapy on fetal growth in pregnancies with early-onset fetal growth restriction. DESIGN: A randomised placebo-controlled trial. SETTING: Thirteen maternal-fetal medicine units across New Zealand and Australia. POPULATION: Women with singleton pregnancies affected by fetal growth restriction at 22+0 to 29+6 weeks. METHODS: Women were randomised to oral administration of 25 mg sildenafil citrate or visually matching placebo three times daily until 32+0 weeks, birth or fetal death (whichever occurred first). MAIN OUTCOME MEASURES: The primary outcome was the proportion of pregnancies with an increase in fetal growth velocity. Secondary outcomes included live birth, survival to hospital discharge free of major neonatal morbidity and pre-eclampsia. RESULTS: Sildenafil did not affect the proportion of pregnancies with an increase in fetal growth velocity; 32/61 (52.5%) sildenafil-treated, 39/57 (68.4%) placebo-treated [adjusted odds ratio (OR) 0.49, 95% CI 0.23-1.05] and had no effect on abdominal circumference Z-scores (P = 0.61). Sildenafil use was associated with a lower mean uterine artery pulsatility index after 48 hours of treatment (1.56 versus 1.81; P = 0.02). The live birth rate was 56/63 (88.9%) for sildenafil-treated and 47/59 (79.7%) for placebo-treated (adjusted OR 2.50, 95% CI 0.80-7.79); survival to hospital discharge free of major neonatal morbidity was 42/63 (66.7%) for sildenafil-treated and 33/59 (55.9%) for placebo-treated (adjusted OR 1.93, 95% CI 0.84-4.45); and new-onset pre-eclampsia was 9/51 (17.7%) for sildenafil-treated and 14/55 (25.5%) for placebo-treated (OR 0.67, 95% CI 0.26-1.75). CONCLUSIONS: Maternal sildenafil use had no effect on fetal growth velocity. Prospectively planned meta-analyses will determine whether sildenafil exerts other effects on maternal and fetal/neonatal wellbeing. TWEETABLE ABSTRACT: Maternal sildenafil use has no beneficial effect on growth in early-onset FGR, but also no evidence of harm.

Metastatic gestational choriocarcinoma: a masquerader in obstetrics.

We describe a case of a 36-year-old woman presenting with vaginal bleeding and suboptimally rising serum human chorionic gonadotropin levels, who was investigated for a pregnancy of unknown location. Ultrasonography, laparoscopy and dilatation and curettage failed to reveal signs of an intra-uterine or intra-abdominal pregnancy. Following computed tomography imaging, a mediastinal mass was histologically determined to be a gestational choriocarcinoma. Following surgical resection and chemotherapy, the patient recovered and proceeded to have a successful intra-uterine pregnancy. We describe this exceptionally rare case and emphasise the importance of follow-up of hCG levels in pregnancy of unknown location.

Born before arrival births: impact of a changing obstetric population.

This retrospective cohort study examined 143/39,895 (0.36%) consecutive born-before-arrival (BBA) births. The incidence of BBA births doubled from 0.26% in 2005 to 0.5% in 2009. This increase was mainly attributed to the increase of non-Irish nationals and patients from low socioeconomic groups attending for antenatal care. Poor social background was often coupled with current or past substance misuse and/or a diagnosis of an infectious disease. While there was no excess in maternal morbidity, the perinatal mortality rate among BBA births was three-fold increased (27.9/1,000) when compared with the overall rate for all inborn babies in our hospital (8.5/1,000) but significantly less than previously published (58.4/1,000). Results of our study call for continuing training of paramedic staff involved in these deliveries and neonatal resuscitation. Given the easy accessibility of antenatal services in Ireland, this study highlights the urgent need for optimising parental education and care in this vulnerable group of patients.

Rising rates of caesarean deliveries at full cervical dilatation: a concerning trend.

OBJECTIVES: To audit caesarean sections performed at full cervical dilatation over a three year period in a tertiary referral centre in Ireland. To evaluate (i) the rate of caesarean deliveries in the second stage of labour, (ii) the indication for delivery and (iii) the associated fetal and maternal morbidity in this cohort of women. STUDY DESIGN: This cohort study was carried out in the University Hospital Galway (UHG). Medical records of 136 consecutive women with singleton cephalic pregnancies at term, identified from the hospital database, who underwent a second stage caesarean section (CS) between 1 January 2006 and 31 December 2008, were reviewed retrospectively and demographic and outcome data were collected. RESULTS: During the study period 2801/10,202 (27.5%) babies were delivered by CS. One hundred and thirty six CS (4.8%) were performed at full dilatation. The rate of CS during the second stage increased from 0.9% in 2006 to 1.8% in 2008. The majority of women were nulliparous (76.5%) and in spontaneous labour (64%). 44.1% of women had a second stage CS without a trial of instrumental delivery. 41.3% of public deliveries were attended by a consultant. The majority of babies (54%) were delivered because of a prolonged second stage with a mean duration of 146 min from full dilatation to delivery. Twenty-four of 59 primiparous women (40.7%), who underwent CS because of a prolonged second stage, did not receive oxytocin. 13.2% of babies were admitted to the neonatal intensive care unit. Estimated blood loss was documented in 67% of cases (n=91); 14.3% of women (n=13) had a postpartum haemorrhage greater than or equal to 1000 mls. 23% of these women (n=3) required a blood transfusion. The overall blood transfusion rate was 2.2%. 50% of women had a hospital stay of greater than four days. CONCLUSIONS: There is a worrying rise in the overall rate of CS at full dilatation. Audit of the second stage CS rate is a useful measure of clinical standards. Strategies for improved care include increased consultant presence, meticulous documentation and ongoing training of junior obstetric staff to ensure safe intrapartum care. CONDENSATION: The increase of second stage caesarean sections requires urgent strategies for improved care including increased consultant presence, meticulous documentation and training of junior obstetric staff.

The management of reduced fetal movements in an uncomplicated pregnancy at term: results from an anonymous national online survey in the Republic of Ireland.

There is currently inconsistent evidence and clinical guidance on how to best manage a pregnancy complicated by reduced fetal movements. This novel, web-based, anonymous questionnaire evaluated 96 assessment and management approaches from doctors working in obstetrics in the Republic of Ireland who were presented with a clinical scenario of a primigravida concerned about reduced fetal movements at 39+3 weeks' gestation. This study identified a lack of clinical practice guidelines available in maternity hospitals in the Republic of Ireland. We demonstrated that almost all clinicians applied more than one assessment method and that most incorporated a cardiotocograph into their assessment. There was a low uptake of simple symphysio-fundal height measurement and high usage of kickcharts. The minority of clinicians admitted or induced their patients. This survey identified the need for national and international guidelines to ensure safe antepartum care and delivery.