Interventions for treating genital Chlamydia trachomatis infection in pregnancy.

BACKGROUND: Genital Chlamydia trachomatis (C.trachomatis) infection may lead to pregnancy complications such as miscarriage, preterm labour, low birthweight, preterm rupture of membranes, increased perinatal mortality, postpartum endometritis, chlamydial conjunctivitis and C.trachomatis pneumonia.This review supersedes a previous review on this topic. OBJECTIVES: To establish the most efficacious and best-tolerated therapy for treatment of genital chlamydial infection in preventing maternal infection and adverse neonatal outcomes. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (26 June 2017) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) as well as studies published in abstract form assessing interventions for treating genital C.trachomatis infection in pregnancy. Cluster-RCTs were also eligible for inclusion but none were identified. Quasi-randomised trials and trials using cross-over design are not eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies for inclusion, assessed trial quality and extracted the data using the agreed form. Data were checked for accuracy. Evidence was assessed using the GRADE approach. MAIN RESULTS: We included 15 trials (involving 1754 women) although our meta-analyses were based on fewer numbers of studies/women. All of the included studies were undertaken in North America from 1982 to 2001. Two studies were low risk of bias in all domains, all other studies had varying risk of bias. Four other studies were excluded and one study is ongoing.Eight comparisons were included in this review; three compared antibiotic (erythromycin, clindamycin, amoxicillin) versus placebo; five compared an antibiotic versus another antibiotic (erythromycin, clindamycin, amoxicillin, azithromycin). No study reported different antibiotic regimens. Microbiological cure (primary outcome) Antibiotics versus placebo: Erythromycin (average risk ratio (RR) 2.64, 95% confidence interval (CI) 1.60 to 4.38; two trials, 495 women; I2 = 68%; moderate-certainty evidence), and clindamycin (RR 4.08, 95% CI 2.35 to 7.08; one trial, 85 women;low-certainty evidence) were associated with improved microbiological cure compared to a placebo control. In one very small trial comparing amoxicillin and placebo, the results were unclear, but the evidence was graded very low (RR 2.00, 95% CI 0.59 to 6.79; 15 women). One antibiotic versus another antibiotic: Amoxicillin made little or no difference in microbiological cure in comparison to erythromycin (RR 0.97, 95% CI 0.93 to 1.01; four trials, 466 women; high-certainty evidence), probably no difference compared to clindamycin (RR 0.96, 95% CI 0.89 to 1.04; one trial, 101 women; moderate-quality evidence), and evidence is very low certainty when compared to azithromycin so the effect is not certain (RR 0.89, 95% CI 0.71 to 1.12; two trials, 144 women; very low-certainty evidence). Azithromycin versus erythromycin (average RR 1.11, 95% CI 1.00 to 1.23; six trials, 374 women; I2 = 53%; moderate-certainty evidence) probably have similar efficacy though results appear to favour azithromycin. Clindamycin versus erythromycin (RR 1.06, 95% CI 0.97 to 1.15; two trials, 173 women; low-certainty evidence) may have similar numbers of women with a microbiological cure between groups.Evidence was downgraded for design limitations, inconsistency, and imprecision in effect estimates. Side effects of the treatment (maternal) (secondary outcome) Antibiotics versus placebo: side effects including nausea, vomiting, and abdominal pain, were reported in two studies (495 women) but there was no clear evidence whether erythromycin was associated with more side effects than placebo and a high level of heterogeneity (I2 = 78%) was observed (average RR 2.93, 95% CI 0.36 to 23.76). There was no clear difference in the number of women experiencing side effects when clindamycin was compared to placebo in one small study (5/41 versus 1/44) (RR 6.35, 95% CI 0.38 to 107.45, 62 women). The side effects reported were mostly gastrointestinal and also included resolving skin rashes. One antibiotic versus another antibiotic: There was no clear difference in incidence of side effects (including nausea, vomiting, diarrhoea and abdominal pain) when amoxicillin was compared to azithromycin based on data from one small study (36 women) (RR 0.56, 95% CI 0.24 to 1.31).However, amoxicillin was associated with fewer side effects compared to erythromycin with data from four trials (513 women) (RR 0.31, 95% CI 0.21 to 0.46; I2 = 27%). Side effects included nausea, vomiting, diarrhoea, abdominal cramping, rash, and allergic reaction.Both azithromycin (RR 0.24, 95% CI 0.17 to 0.34; six trials, 374 women) and clindamycin (RR 0.44, 95% CI 0.22 to 0.87; two trials, 183 women) were associated with a lower incidence of side effects compared to erythromycin. These side effects included nausea, vomiting, diarrhoea and abdominal cramping.One small study (101 women) reported there was no clear difference in the number of women with side effects when amoxicillin was compared with clindamycin (RR 0.57, 95% CI 0.14 to 2.26; 107 women). The side effects reported included rash and gastrointestinal complaints. Other secondary outcomes Single trials reported data on repeated infections, preterm birth, preterm rupture of membranes, perinatal mortality and low birthweight and found no clear differences between treatments.Many of this review's secondary outcomes were not reported in the included studies. AUTHORS' CONCLUSIONS: Treatment with antibacterial agents achieves microbiological cure from C.trachomatis infection during pregnancy. There was no apparent difference between assessed agents (amoxicillin, erythromycin, clindamycin, azithromycin) in terms of efficacy (microbiological cure and repeat infection) and pregnancy complications (preterm birth, preterm rupture of membranes, low birthweight). Azithromycin and clindamycin appear to result in fewer side effects than erythromycin.All of the studies in this review were conducted in North America, which may limit the generalisability of the results. In addition, study populations may differ in low-resource settings and these results are therefore only applicable to well-resourced settings. Furthermore, the trials in this review mainly took place in the nineties and early 2000's and antibiotic resistance may have changed since then.Further well-designed studies, with appropriate sample sizes and set in a variety of settings, are required to further evaluate interventions for treating C.trachomatis infection in pregnancy and determine which agents achieve the best microbiological cure with the least side effects. Such studies could report on the outcomes listed in this review.

Prematurity and neonatal outcome including congenital malformations after maternal malignancy within six months prior to or during pregnancy.

INTRODUCTION: The proportion of women who postpone childbearing is increasing. As malignancy risk increases with age, pregnancy in connection with malignancy will become more common. MATERIAL AND METHODS: We compared infants born 1994-2011 to women with a malignancy within six months prior to the last menstrual period or during pregnancy with offspring of women without a previous malignancy. Five national registers were used. RESULTS: A total of 790 women with a malignancy diagnosis from six months prior to the last menstrual period up to delivery were identified. Their 802 infants were compared with 1 742 757 infants of women without a malignancy. A high rate of prematurity was found, especially when the malignancy was diagnosed during the second or third trimesters (33%). Most of these premature births were the result of induced delivery before 35 weeks (91%). The most remarkable finding is the observation that these premature infants had a significantly higher risk for neonatal morbidity than premature infants in the control group with an adjusted odds ratio of 2.67 (95% confidence interval; 1.86-3.84). We found a significantly increased risk of mainly relatively mild malformations among infants of women with a malignancy diagnosis within six months prior to the last menstrual period or during the first trimester with a risk ratio of 1.81 (95% confidence interval; 1.20-2.61). CONCLUSIONS: A high incidence of prematurity, mostly due to induced delivery, was found, including an increased risk for neonatal morbidity among these infants. An increased risk for relatively mild malformations was also found.

Characteristics of the Offspring of Women with a History of Malignancy, Excluding Congenital Malformations.

OBJECTIVE: To study the characteristics (except congenital malformations) of offspring born to women with a history of malignancy. METHODS: Data were obtained by linkage between four different Swedish national health registers. We compared the offspring born between 1994 and 2011 of women with a history of malignancy with all other infants. Survival of the infants was followed up through 2013. Adjusting for confounders was performed using Mantel-Haenszel methodology. We identified 7315 infants born to women with a history of a malignancy diagnosed at least 1 year before delivery. The total number of deliveries in Sweden in these years was 1 746 870, with 1 780 112 infants being born. We assessed rates of intrauterine death, preterm birth, low birth weight, and the nature of intrauterine growth. We also examined neonatal diagnoses (asphyxia, chronic respiratory condition, intracranial hemorrhage, jaundice, hypoglycemia, CNS symptoms) and infant death. RESULTS: In women with a history of malignancy, we found no significantly increased risk for stillbirth or infant death. There were elevated rates of preterm birth (OR 1.50, 95% CI 1.37 to 1.64), very preterm birth (OR 1.89, 95% CI 1.54 to 2.32), and low birth weight (OR 1.50, 95% CI 1.34 to 1.68). There was a significantly increased risk of birth asphyxia, jaundice, hypoglycemia, and low Apgar score among infants born to women with a history of malignancy (OR 1.24, 95% CI 1.15 to 1.33), and this risk was maintained after excluding infants born after IVF. CONCLUSION: We found an increased risk of preterm birth and low birth weight among infants of women with a history of malignancy, and as a result, found an increased risk of neonatal morbidity. No significant increase in risk of intrauterine or postnatal death was noted.

Changes in human fetal oxygenation during maternal hyperoxia as estimated by BOLD MRI.

OBJECTIVE: Changes in blood oxygen level dependent (BOLD) magnetic resonance imaging (MRI) signal are closely related to changes in fetal oxygenation. In this study, we aimed to investigate the changes in human fetal oxygenation during maternal hyperoxia by using the non-invasive BOLD MRI technique. METHOD: Eight healthy pregnant women in gestational week 28 to 34 were included. With the use of a facial oxygen mask, we induced maternal hyperoxia and measured changes in the BOLD MRI signal of selected fetal organs. RESULTS: In a number of fetal organs, the BOLD MRI signal increased significantly (P < 0.01) during maternal hyperoxia (mean change in % ± SEM): liver (14.3 ± 3.7%), spleen (15.2 ± 3.5%) and kidney (6.2 ± 1.8%) as well as the placenta (6.5 ± 1.6%). In the fetal brain, however, the BOLD MRI signal remained constant (0.3 ± 0.2%). CONCLUSION: During maternal hyperoxia, we demonstrated an increased oxygenation in a number of human fetal organs by using the non-invasive BOLD technique. The oxygenation of the fetal brain remained constant, thus a 'reversed' brain sparing mechanism could be considered in healthy fetuses subjected to hyperoxia.

Apparently isolated ventricular septal defect, prenatal diagnosis, association with chromosomal aberrations, spontaneous closure rate in utero and during the first year of life: a systematic review.

AIM: To evaluate the incidence of chromosomal aberrations in apparently isolated ventricular septal defects (VSD), quantify the timing of diagnosis of prenatally diagnosed VSDs, and define the spontaneous closure rate prenatally both in utero and during the first year of life.

Attitudes of midwives in Sweden toward a woman's refusal of an emergency cesarean section or a cesarean section on request.

BACKGROUND: A woman's refusal or request for a cesarean section can be a problem for midwives and obstetricians working in maternity units. The objective of this study was to describe the attitudes of midwives in Sweden toward the obstetrician's decision making in relation to a woman's refusal of an emergency cesarean section and to a woman's request for a cesarean section without a medical indication. METHODS: The study has a cross-sectional multicenter design and used an anonymous, structured, and standardized questionnaire for data collection. The study group comprised midwives who had experience working at a delivery ward at 13 maternity units with neonatal intensive care units in Sweden (n = 259). RESULTS: In the case of a woman's refusal to undergo an emergency cesarean section for fetal reasons, most midwives (89%) thought that the obstetrician should try to persuade the woman to agree. Concerning a woman's request for a cesarean section without any medical indications, most midwives thought that the obstetrician should agree if the woman had previous maternal or fetal complications. The reason was to support the woman's decision out of respect for her autonomy; the midwives at six university hospitals were less willing to accept the woman's autonomy in this situation. If the only reason was "her own choice," 77 percent of the midwives responded that the obstetrician should not comply. CONCLUSIONS: The main focus of midwives seems to be the baby's health, and therefore they do not always agree with respect to a woman's refusal or request for a cesarean section. The midwives prefer to continue to explain the situation and persuade the woman to agree with the recommendation of the obstetrician.

Fusion imaging in brain structure measurements on a fetus phantom, combining real-time ultrasound with magnetic resonance imaging.

OBJECTIVES: To assess synchronisation of MRI and US in measuring foetus phantom head structures; inter-method, intra- and inter-observer differences on biparietal diameter (BPD), head diameter, anterio-posterior head diameter (HAP) and lateral ventricle structures (VS). METHODS: Fusion Imaging (FI) has been performed by combining MRI and US simultaneously. Axial scans of 1.5 Tesla MRI on a foetus phantom were acquired and uploaded on a US machine (EPIQ 7G, Philips). A PercuNav US tracker allowed the system to recognise and display the position of the transducer. A fetal phantom tracker was used as a phantom reference. Real-time US of the phantom head was performed by synchronising the uploaded MRI images using different landmarks. Synchronisation has been assessed by taking measurements after rotating the US probe by 90. Measurements were taken by three different observers twice. Differences in measurements between MRI and US, inter-, intra-observer differences in all measurements were assessed. RESULTS: BPD, HAP and VS measurements before rotation were 0.13 ± 0.06 cm, 0.46 ± 0.09 cm and 0.4 ± 0.23 cm (width) and mean 0.6 ± 0.25 cm (length) larger at MRI than at US using any number of landmarks. After US probe rotation VS were 0.3 ± 0.24 cm in width and 0.3 ± 0.27 cm in length. Intra- and inter-observer differences in all measurements were small. CONCLUSIONS: FI showed good synchronisation in measurements. BPD, HAP and VS were larger at MRI than US, likely a result of the way images are generated. Intra-, inter-observer differences between measurements were small. This can be important when reporting geometric measures from FI.

Cesarean delivery on maternal request: can the ethical problem be solved by the principlist approach?

In this article, we use the principlist approach to identify, analyse and attempt to solve the ethical problem raised by a pregnant woman's request for cesarean delivery in absence of medical indications. We use two different types of premises: factual (facts about cesarean delivery and specifically attitudes of obstetricians as derived from the EUROBS European study) and value premises (principles of beneficence and non-maleficence, respect for autonomy and justice).Beneficence/non-maleficence entails physicians' responsibility to minimise harms and maximise benefits. Avoiding its inherent risks makes a prima facie case against cesarean section without medical indication. However, as vaginal delivery can have unintended consequences, there is a need to balance the somewhat dissimilar risks and benefits. The principle of autonomy poses a challenge in case of disagreement between the pregnant woman and the physician. Improved communication aimed to enable better informed choice may overcome some instances of disagreement. The principle of justice prohibits unfair discrimination, and broadly favours optimising resource utilisation. Available evidence supports vaginal birth in uncomplicated term pregnancies as the standard of care. The principlist approach offered a useful framework for ethical analysis of cesarean delivery on maternal request, identified the rights and duties of those involved, and helped reach a conclusion, although conflict at the individual level may remain challenging.

Congenital malformations in offspring of women with a history of malignancy.

BACKGROUND: Survival after malignancy has increased and the question of risks, including risk for congenital malformations for the offspring of these women has become important. Data on congenital malformations in such offspring are limited. METHODS: We compared congenital malformation in offspring, born 1994 to 2011 of women with a history of malignancy (at least 1 year before delivery) with all other offspring. Adjustment for confounders was mainly made by Mantel-Haenszel methodology. Data were obtained by linkage between Swedish national health registers. RESULTS: We identified 71,954 (4.1%) infants with congenital malformation, of which 47,081 (2.7%) were relatively severe (roughly corresponding to major malformation). Among 7284 infants to women with a history of malignancy 204 relatively severe malformations were found (2.8%; odds ratio [OR] = 1.04; 95% confidence interval [CI], 0.91-1.20). After in vitro fertilization, the risk of a relatively severe malformation was significantly increased in women without a history of malignancy (OR = 1.31; 95% CI, 1.24-1.38) and still more in women with such a history (risk ratio = 1.85; 95% CI, 1.08-2.97). However, there were no significant differences neither, for any malformations (OR = 1.04; 95% CI, 0.92-1.16) nor for relatively severe malformations (OR = 1.04; 95% CI, 0.91-1.20), when comparing offspring only after maternal history of malignancy. CONCLUSION: No general increase in malformation rate was found in infants born to women with a history of malignancy. A previously known increased risk after in vitro fertilization was verified and it is possible that this risk is further augmented among infants born of women with a history of malignancy. Birth Defects Research 109:224-233, 2017. © 2016 Wiley Periodicals, Inc.

Deliveries After Malignant Disease Before Pregnancy: Maternal Characteristics, Pregnancy, and Delivery Complications.

PURPOSE: Survival after cancer has increased, and the question of risks in later pregnancies has become important. A previous malignancy may affect pregnancy outcome. METHODS: Comparison of women with malignant disease before pregnancy with all other women giving birth during 1994-2011. Data were obtained by linkage between Swedish national health registers. Subfertility, evaluated as time to pregnancy, and in vitro fertilization (IVF) before the relevant delivery were studied. The following delivery diagnoses were studied: gestational diabetes, preeclampsia, placenta previa, placenta abruption, placenta retention, bleeding around delivery, and premature rupture of membranes. The rates of cesarean section and vacuum extraction or forceps delivery were also studied. RESULTS: We identified 3931 women with 7176 deliveries and with a malignancy diagnosed at least 1 year before the delivery. The total number of deliveries in Sweden in these years was 1,746,870. Overall, an increased risk of subfertility (odds ratio [OR] 1.17, 95% confidence interval [CI] 1.07-1.28), use of IVF (OR = 1.36, CI 1.21-1.53), delivery complications (OR = 1.17, 95% CI 1.10-1.24), and rate of caesarean sections (OR = 1.27, 95% CI 1.20-1.34) was observed among women with a history of malignancy compared with other women. CONCLUSION: We found an increased risk of subfertility, pregnancy, and delivery complications in women with a history of malignant disease. Further studies are needed to evaluate the risks of specific treatments and to provide these women with reliable information that could affect their family planning.

Perinatal adaptive response of the adrenal and carotid blood flow in sheep fetuses subjected to total cord occlusion.

OBJECTIVE: To investigate the perinatal adaptive response of the adrenal blood flow/adrenal fractional moving blood volume (AFMBV) and carotid blood flow (CBF), in sheep fetuses subjected to severe acute intrauterine hypoxia/asphyxia induced by total cord occlusion. METHODS: Adrenal blood flow velocity, AFMBV and CBF were measured in 13 exteriorized fetal sheep; eight of them underwent total umbilical cord occlusion to induce severe acute hypoxia/asphyxia. Five lambs were used as sham controls. Middle adrenal artery pulsatility index (MAAPI) and mean velocity (MAAMV) were recorded with pulsed Doppler ultrasound. AFMBV was estimated using power Doppler ultrasound. CBF was recorded with a transonic flowmeter. In the neonatal period, after resuscitation all lambs were followed for a 4-hour period and AFMBV and CBF were recorded. Mean arterial blood pressure (MABP) and fetal heart rate were recorded continuously. Arterial cortisol levels were measured at the beginning and at the end of the fetal and neonatal periods. RESULTS: Following the total cord occlusion, there was a significant reduction in the CBF, MABP, and heart rate and adrenal flow/AFMBV after 2, 4 and 5 min, respectively. Cortisol levels in the asphyctic lambs at the end of the cord occlusion were significantly lower than those in controls. After resuscitation, the asphyctic lambs showed increased AFMBV and cortisol levels, and reduced MABP as compared to control lambs. No differences were found in CBF, MAAPI and MAAMV. Thereafter, no differences were observed between the two groups in any of the studied parameters. At the end of the cord occlusion period, there was a significant correlation between AFMBV and MABP (r=0.69), between AFMBV and CBF (r =0.65) and between CBF and MABP (r=0.89). CONCLUSION: During severe acute intrauterine hypoxia, the fetal lamb is able to maintain the blood flow to the brain and the adrenal gland for 3-5 min. Changes in the AFMBV and the CBF were highly correlated to the changes in MABP. Adrenal FMBV and cortisol levels were higher in lamb neonates exposed to severe intrauterine asphyxia.

[LD isoenzyme in uterine aspirates a potential marker of endometrial cancer. Investigation of postmenopausal bleeding can be simpler and cheaper]. / LD-isoenzym i uterusaspirat potentiell markör för endometriecancer. Utredning av postmenopausal blödning kan bli enklare och billigare.

In diagnosing endometrial carcinoma in women with postmenopausal bleeding analysis of lactate dehydrogenase, LD, isoenzymes in uterine aspirates appeared to have 100 percent sensitivity and negative predictive value combined with high specificity and positive predictive value. Determination of the LD-profile is suggested as a marker for endometrial carcinoma in women with postmenopausal bleeding. Transvaginal ultrasonography might be combined with determination of the LD-isoenzyme profile to secure the diagnosis of endometrial malignancy in order to minimize the use of other more invasive diagnostic methods.

Estimation of fractional moving blood volume in fetal lung using Power Doppler ultrasound, methodological aspects.

Perfusion estimation of the fetal lung is an important predictor of its maturity and function after birth. Ultrasound (US) power Doppler has previously been used to assess the perfusion of the fetal lung, based on the mean pixel intensity (MPI) over a region-of-interest (ROI). The drawback is that the MPI is not only dependent on the amount of flowing blood, but also depth, gain and attenuation in overlying tissue layers. In this study, power Doppler images have been analysed according to a previously published method that attempts to compensate for such unwanted variations, resulting in a measure termed fractional moving blood volume (FMBV). A total of 29 singleton pregnancies with normally grown fetuses were evaluated after 35 weeks of gestation. For reliable interpatient comparisons, we found it always necessary to use a well-defined section of the fetal lung. Therefore, all scans were performed in a transverse plane of the fetal thorax with a four-chamber view of the heart, through the intercostal space. ROIs in 12 left and 17 right fetal lungs were defined (the fetal lung closest to the transducer was always examined). No differences in estimated FMBV or MPI were found between left and right lungs. Similarly, there was no significant difference between images acquired during systole and diastole. FMBV is compensated for depth and, also, for other sources of power variation, as reflected in the coefficient of variation: 0.14 for FMBV and 0.24 for MPI. A scan on a test phantom reveals that the power in dB is linearly related to velocity over a limited range, suggesting that FMBV might be useful for discriminating between normal and decreased fetal lung perfusion.

Lung fractional moving blood volume in normally grown and growth restricted foetuses.

OBJECTIVE: To examine foetal lung blood perfusion using power Doppler ultrasound (PDU) and to compare fractional moving blood volume (FMBV) and mean pixel intensity (MPI) estimations in the lungs of normally grown (NG) foetuses and foetuses with intrauterine growth restriction (IUGR) and also to correlate foetal lung FMBV and MPI with respiratory complications after birth. METHODS: Lungs of 47 NG and 25 IUGR foetuses after 32 weeks of gestation were examined with PDU. FMBV and MPI were estimated in a defined region in the posterior part of the foetal lung closest to maternal abdominal wall. FMBV and MPI were correlated to foetal weight deviation and gestational age. Perinatal outcome and respiratory complications after birth were recorded in both groups. RESULTS: There were significantly lower FMBV and MPI values in IUGR than in NG foetuses. The overall variation was lower for FMBV than for MPI. There was a slightly higher correlation between FMBV and foetal weight deviation [r = 0.33, 95% confidence intervals (CI) 0.11-0.52] than between MPI and foetal weight deviation (r = 0.26, 95% CI 0.03-0.46). There was no significant correlation between FMBV or MPI and gestational age. No differences between the groups were found in the rate of respiratory complications, and they were not correlated either to the FMBV or MPI. CONCLUSION: FMBV and MPI, estimated from the PDU signals of foetal lung circulation, showed lower values in third-trimester pregnancies complicated by IUGR. The frequency of neonatal respiratory complications was not increased in cases with low pulmonary FMBV and MPI values.

Operator auditory perception and spectral quantification of umbilical artery Doppler ultrasound signals.

OBJECTIVE: An experienced sonographer can by listening to the Doppler audio signals perceive various timbres that distinguish different types of umbilical artery flow despite an unchanged pulsatility index (PI). Our aim was to develop an objective measure of the Doppler audio signals recorded from fetoplacental circulation in a sheep model. METHODS: Various degrees of pathological flow velocity waveforms in the umbilical artery, similar to those in human complicated pregnancies, were induced by microsphere embolization of the placental bed (embolization model, 7 lamb fetuses, 370 Doppler recordings) or by fetal hemodilution (anemia model, 4 lamb fetuses, 184 recordings). A subjective 11-step operator auditory scale (OAS) was related to conventional Doppler parameters, PI and time average mean velocity (TAM), and to sound frequency analysis of Doppler signals (sound frequency with the maximum energy content [MAXpeak] and frequency band at maximum level minus 15 dB [MAXpeak-15 dB] over several heart cycles). RESULTS: WE FOUND A NEGATIVE CORRELATION BETWEEN THE OAS AND PI: median Rho -0.73 (range -0.35- -0.94) and -0.68 (range -0.57- -0.78) in the two lamb models, respectively. There was a positive correlation between OAS and TAM in both models: median Rho 0.80 (range 0.58-0.95) and 0.90 (range 0.78-0.95), respectively. A strong correlation was found between TAM and the results of sound spectrum analysis; in the embolization model the median r was 0.91 (range 0.88-0.97) for MAXpeak and 0.91 (range 0.82-0.98) for MAXpeak-15 dB. In the anemia model, the corresponding values were 0.92 (range 0.78-0.96) and 0.96 (range 0.89-0.98), respectively. CONCLUSION: Audio-spectrum analysis reflects the subjective perception of Doppler sound signals in the umbilical artery and has a strong correlation to TAM-velocity. This information might be of importance for clinical management of complicated pregnancies as an addition to conventional Doppler parameters.

Attitudes of Swedish midwives towards management of extremely preterm labour and birth.

OBJECTIVE: the aim of the study was to ascertain the attitudes of Swedish midwives towards management of very preterm labour and birth and to compare the attitudes of midwives at university hospitals with those at general hospitals. DESIGN: this cross-sectional descriptive and comparative study used an anonymous self-administrated questionnaire for data collection. Descriptive and analytic statistics were carried out for analysis. PARTICIPANTS: the answers from midwives (n=259) were collected in a prospective SWEMID study. SETTING: the midwives had experience of working on delivery wards in maternity units with neonatal intensive care units (NICU) in Sweden. FINDINGS: in the management of very preterm labour and birth, midwives agreed to initiate interventions concerning steroid prophylaxis at 23 gestational weeks (GW), caesarean section for preterm labour only at 25 GW, when to give information to the neonatologist before birth at 23 GW, and when to suggest transfer to NICU at 23 GW. Midwives at university hospitals were prone to start interventions at an earlier gestational age than the midwives at general hospitals. Midwives at university hospitals seemed to be more willing to disclose information to the parents. KEY CONCLUSIONS: midwives with experience of handling very preterm births at 21-28 GW develop a positive attitude to interventions at an earlier gestational age as compared to midwives without such experience. IMPLICATIONS FOR PRACTICE: based on these results we suggest more communication and transfer of information about the advances in perinatal care and exchange of knowledge between the staff at general and university hospitals. Establishment of platforms for inter-professional discussions about ethically difficult situations in perinatal care, might benefit the management of very preterm labour and birth.

Management of pregnancy and labour in cases diagnosed with major fetal malformation.

PURPOSE OF REVIEW: To explore the obstetrical management of pregnancies with severe fetal malformations, taking into account the rapid improvement in ultrasound technology and interventional possibilities. RECENT FINDINGS: Unique studies using modern ultrasound techniques describe the evolution of spina bifida and the subsequent varying development of hydrocephalus. In addition, the dilated fetal stomach is shown to be an ominous sign of complications in cases of gastroschisis. Such complications can be decreased by prenatal supervision using cardiotocography, which detects signs of fetal distress. Recent studies confirm previous findings that caesarean section does not improve the outcome in cases of fetal gastroschisis or spina bifida. SUMMARY: Recent research has demonstrated the development of severe fetal malformations. New studies have shown the positive effects of fetal supervision in cases of gastroschisis. Furthermore, caesarean section is not beneficial compared with vaginal delivery in such cases. Fetal surgery is still undergoing rapid development and has the potential to improve outcome in the near future.

Hyrtl's anastomosis is normally developed in placentas from small for gestational age infants.

BACKGROUND: The aim of this study was to investigate the occurrence and appearance of the anastomosis between the two umbilical arteries in placentas from infants small for gestational age (SGA). METHODS: The arterial systems of 64 placentas from singleton pregnancies resulting in SGA infants were visualized by angiography. The method allowed study of the anastomosis between the umbilical arteries and calculation of the relative placental area supplied by each artery. The results were compared with findings in a previous study of appropriate for gestational age (AGA) infants. One-way analysis of variance (ANOVA) and chi2-analyses were used for statistics. RESULTS: In 56 placentas the anastomosis was represented by a true vessel, in two by a fenestration, and in another two cases by fusion of the umbilical arteries. The anastomosis was absent in one case and another three cases had a single umbilical artery (SUA). When the diameter of the anastomosis was thinner than that of the umbilical arteries, their supply areas were significantly (p < or = 0.001) more symmetrical than in cases with a wider anastomosis. The anatomy of the anastomosis and the relationship between its width and the symmetry between the supply areas of each umbilical artery did not differ in placentas from SGA and AGA infants, despite various types of cord insertion and placentation. CONCLUSION: Static measurements of Hyrtl's anastomosis do not indicate a contributing part for intrauterine growth retardation.

Different responses of myocardial and cerebral blood flow to cord occlusion in exteriorized fetal sheep.

Type and duration of fetal asphyxial insult affect the distribution of blood flow to the heart and brain. The purpose of this study was to describe dynamic and quantitative changes in regional myocardial and cerebral blood flow (CBF) during fetal asphyxia induced by total occlusion of the umbilical cord. Eleven exteriorized fetal sheep were subjected to total umbilical cord occlusion and five fetal sheep served as sham controls. Regional blood flow (BF) to the brain and heart was quantified using radioactive microspheres before and after 5 min of occlusion and finally when fetal mean arterial blood pressure had decreased below 25 mm Hg, 9.8 (0.8) [mean (SD)] min after occlusion. Right coronary arterial (RCA) blood flow velocity and carotid BF were registered continuously. Mean values of arterial pH and oxygen content (mL O(2)/100 mL) were 7.08 (0.11) and 4.4 (2.9) before cord occlusion and decreased to 6.83 (0.05) and 1.4 (0.9) at 5 min after occlusion (p < 0.01, respectively). Carotid BF was significantly below preocclusion values by 2.5 min (p < 0.05), whereas RCA velocity time integral per minute remained above preocclusion values for 9 min. CBF decreased from 316 (24) before cord occlusion to 156 (30) mL/min/100 g at 5 min (p < 0.01), whereas right myocardial BF was maintained at 792 (125) and 751 (183) mL/min/100 g, respectively. CBF decreased rapidly after total cord occlusion whereas myocardial BF increased and was maintained until shortly before cardiac arrest, suggesting the myocardium to be better preserved during this type of insult in already partially asphyxiated fetuses.