Homelessness in pregnancy

OBJECTIVES

To evaluate the association, if any, of homelessness or refuge accommodation on delivery and short term perinatal outcomes in an Irish tertiary maternity hospital.

METHODS

A retrospective cohort study of 133 singleton pregnancies in women reporting to be homeless or living in refuge at their booking antenatal appointment between 2013 and 2022. Analysis compared sociodemographic characteristics and perinatal outcomes in this cohort to a reference population of 76,858 women with stable living arrangements.

RESULTS

Women in the homeless/refuge population were statistically more likely to be single (75.2 % vs 39.5 %, p < 0.001), have an unplanned pregnancy (73.7 % vs 27.2 %, p < 0.001), report a history of psychiatric illness (42.9 % vs 22.4 %, p < 0.001), domestic violence (18.8 % vs 0.9 %, p < 0.001) alcohol consumption in pregnancy (3.0 % vs 0.8 %, p < 0.001) or smoking in pregnancy (41.3 % vs 9.7 %, p < 0.001). They were significantly more likely to have a preterm birth (adjusted OR 1.71 (1.01-2.87) p = 0.04). They also had a significantly lower median birth weight compared to the reference population (birthweight 3270 g vs 3420 g, p < 0.001).

CONCLUSION

Women in the homeless and refuge population are more likely to experience poorer perinatal outcomes compared to women with stable living arrangements.

Re-evaluation of umbilical cord coiling index in adverse pregnancy outcome - Does it have role in obstetric management?

Introduction

The placenta with the umbilical cord is a vital link between the mother and fetus. Umbilical cord supplies water, nutrients and oxygen from the mother to the fetus. The most unique character of the umbilical cord is its coiling, where the contents of the cord course in a coiled helical fashion. The umbilical coiling index(UCI) can be measured antenatally using ultrasonography. In the present study we have attempted to assess the UCI antenatally by ultrasound screening and correlate abnormal antenatal UCI with the adverse maternal and neonatal outcome of pregnancy.

Aims

To study umbilical coiling index ultrasonographically and to correlate it with pregnancy outcome.

Methodology

150 antenatal cases in the second trimester of pregnancy between 22 and 28weeks of gestation attending the outpatient department were included for the study in a continuous manner and subjected to antenatal UCI measurement. The cases were followed up till delivery and various factors were noted.

Results

We confirmed that maternal medical comorbidities ( gestational hypertension and anemia) have a significant correlation with abnormal umbilical cord coiling index, either hyper-coiling or hypo-coiling or both.Some studies have shown a particular adverse effect being manifested in both hypo and hypercoiling. In the present study significant correlation of abnormal coiling has been found with only anaemia and hypertension in pregnancy. The question, therefore, arises:"Does abnormal UCI have any significant role in prediction of adverse outcome in pregnancy or is it just a random association?" This study does not reflect any significant role of abnormal UCI in the prediction of adverse perinatal outcome. Hence efforts to monitor UCI in the antenatal period may not have any justification in the present scenario. The latest edition of William's Obstetrics also makes a similar comment. A population based larger study to generate cut offs for hypo and hyper coiling and finding any association between abnormal coiling and perinatal outcome may throw more light on the utility of UCI as a predictor of adverse outcome in pregnancy.

Prediction of spontaneous preterm birth using CCL2 and CXCL10 in maternal serum of symptomatic high-risk pregnant women: a prospective cohort study

INTRODUCTION

CCL2 and CXCL10 are putative biomarkers for the prediction of spontaneous preterm birth. This study evaluates these markers in a cohort of pregnant high-risk women.

MATERIAL AND METHODS

In our prospective study, we included 109 women with signs of preterm labor between 20 + 0 and 31 + 6 weeks of gestation. Inclusion criteria were regular (< 3/30 min) or painful contractions, cervical length < 25 mm or a history of previous preterm birth (PTB). Blood samples were obtained upon first admission to our clinic. Biomarker concentrations were measured using pre-coated sandwich immunoassays (ELISA). Primary study outcome was spontaneous preterm birth < 34 weeks, secondary outcome was delivery < 37 weeks or within seven days after study inclusion.

RESULTS

Sixteen women (14.7%) delivered < 34 weeks and twenty women between 34 + 0 and 36 + 6 weeks (18.4%). Six patients (5.5%) gave birth within seven days after study admission. CXCL10 showed higher medium serum levels in women with PTB < 34 weeks (115 pg/ml compared to 61 pg/ml ≥ 34 weeks; p < 0.001) and < 37 weeks (103 pg/ml vs. 53 pg/ml; p < 0.001). In contrary, lower CCL2 serum levels were associated with PTB < 34 weeks (46 pg/ml vs. 73 pg/ml; p = 0.032) and birth within 7 days (25 pg/ml vs. 73 pg/ml; p = 0.008). The CXCL10/CCL2-ratio further improved the predictive model with a ROC-AUC of 0.83 (95% CI 0.73-0.93, p < 0.001) for delivery < 34 weeks. These corresponds to a sensitivity, specificity and positive predictive value of 0.67, 0.86 and 0.43 at a cut-off of 2.2.

CONCLUSION

Low maternal serum CCL2 levels are associated with a higher risk of preterm delivery within seven days. High CXCL10 serum levels are more associated with a high risk for preterm birth < 34 weeks. Elevated CXCL10/CCL2-ratio is showing the best predictive performance.

TRIAL REGISTRATION NUMBER (DRKS-ID)

DRKS00010763, Registration date: September 02, 2016.

Liver stiffness in pregnant women with intrahepatic cholestasis of pregnancy: A case control study

BACKGROUND

Intrahepatic cholestasis of pregnancy (ICP) is a rare but severe complication for both the mother and the unborn child. The diagnosis is primarily based on elevated serum levels of bile acids. In a large ICP cohort, we here study in detail liver stiffness (LS) using transient elastography (TE), now widely used to non-invasively screen for liver cirrhosis within minutes.

AIM

To specifically explore LS in a large cohort of women with ICP compared to a control group with uncomplicated pregnancy.

METHODS

LS and hepatic steatosis marker controlled attenuation parameter (CAP) were measured in 100 pregnant women with ICP using TE (Fibroscan, Echosens, Paris, France) between 2010 and 2020. In 17 cases, LS could be measured postpartum. 450 women before and 38 women after delivery with uncomplicated pregnancy served as control group. Routine laboratory, levels of bile acids and apoptosis marker caspase-cleaved cytokeratin 18 fragment (M30) were also measured.

RESULTS

Women with ICP had significantly elevated transaminases but normal gamma-glutamyl transferase (GGT). Mean LS was significantly increased at 7.3 ± 3.0 kPa compared to the control group at 6.2 ± 2.3 kPa (P < 0.0001). Postpartum LS decreased significantly in both groups but was still higher in ICP (5.8 ± 1.7 kPa vs 4.2 ± 0.9 kPa, P < 0.0001), respectively. In ICP, LS was highly significantly correlated with levels of bile acids and M30 but not transaminases. No correlation was seen with GGT that even increased significantly after delivery in the ICP group. Bile acids were mostly correlated with the liver apoptosis marker M30, LS and levels of alanine aminotransferase, aspartate aminotransferase, and bilirubin. In multivariate analysis, LS remained the sole parameter that was independently associated with elevated bile acids.

CONCLUSION

In conclusion, LS is significantly elevated in ICP which is most likely due to toxic bile acid accumulation and hepatocyte apoptosis. In association with conventional laboratory markers, LS provides additional non-invasive information to rapidly identify women at risk for ICP.

Evaluation of obstetric outcomes in Brazilian pregnant women with Takayasu arteritis

OBJECTIVE

Takayasu arteritis (TAK) is a rare chronic granulomatous vasculitis that affects large vessels and usually begins in women of childbearing age, so it is not uncommon for pregnancies to occur in these patients. However, there is limited information about these pregnancies, with reports of adverse maternal and obstetric outcomes. The objective of this study is to evaluate adverse maternal, fetal and neonatal events in pregnant patients with TA.

METHODS

This is a cross-sectional study with retrospective data collection. We reviewed 22 pregnancies in 18 patients with TAK, according to the American College of Rheumatology criteria, that were followed up in a high-risk prenatal clinic specialized in systemic autoimmune diseases and thrombophilia (PrAT) at Hospital Universitário Pedro Ernesto, from 1998 to 2021.

RESULTS

In twenty-two pregnancies, the mean age of patients was 28.09 years and the mean duration disease was 10.9 years. Of the 18 patients with TAK studied, only one had the diagnosis during pregnancy and had active disease. All other patients had a previous diagnosis of TAK and only 3 had disease activity during pregnancy. Twelve patients (66.6%) had previous systemic arterial hypertension and eleven (61.1%) had renal involvement. Among maternal complications, eight patients (36.3%) developed preeclampsia and six (27.2%) had uncontrolled blood pressure without proteinuria, while 10 (45%) had puerperal complications. Four (18.1%) births were premature, all due to severe preeclampsia and eight newborns (34.7%) were small for gestational age. When all maternal and fetal/neonatal outcomes included in this study were considered, only 6 (27.2%) pregnancies were uneventful.

CONCLUSION

Although there were no maternal deaths or pregnancy losses in this study, the number of adverse events was considerably high. Hypertensive disorders and small for gestational age newborns were more common than general population, while the number of patients with active disease was low. These findings suggest that pregnancies in patients with TAK still have several complications and a high-risk prenatal care and delivery are necessary for these patients.

Pregnancy feasibility in women with mild pulmonary arterial hypertension: a systematic review and meta-analysis

BACKGROUND

The aim of this study was to evaluate the pregnancy feasibility of women with mild pulmonary hypertension according to pregnancy outcomes.

METHODS

This systematic review and meta-analysis compared the differences in maternal and fetal outcomes between mild and moderate-to-severe pulmonary hypertension. Relevant English and Chinese literature were searched in the PubMed, Embase, Cochrane Central Register of Controlled Trials (COCHRANE), CNKI, WanFang Data, and VIP databases between January 1st, 1990 and April 18th, 2023, and the references of the included articles and relevant systematic reviews were reviewed to determine whether studies were missed. The inclusion criteria were randomized controlled and observational studies (including case-control studies and cohort studies) examining maternal and fetal pregnancy outcomes with pulmonary hypertension. Conference abstracts, case reports, case series reports, non-comparative studies, and review articles were excluded.

RESULTS

This meta-analysis included 32 studies. In this study, maternal and fetal outcomes were better in the mild pulmonary hypertension group than in the moderate-to-severe group. Regarding maternal mortality, the mild group was much lower than the moderate to severe group. We found a significant decrease in maternal mortality in the mild group after 2010. However, no significant difference in maternal mortality before and after 2010 was observed in the moderate to severe group. Cardiac complications, ICU admission, neonatal preterm birth, small for gestational age infants, low birth weight infants, neonatal asphyxia, and neonatal mortality were significantly lower in the mild pulmonary hypertension group than in the moderate to severe pulmonary hypertension group. The cesarean section rates of the two groups were similar. However, the vaginal delivery rate in the mild pulmonary hypertension group was significantly higher than that in the moderate to severe pulmonary hypertension group.

CONCLUSIONS

This meta-analysis confirmed that pregnancies with mild pulmonary hypertension had significantly better maternal and fetal outcomes than those with moderate to severe pulmonary hypertension. For patients with mild pulmonary hypertension and good cardiac function, continued pregnancy or even delivery should be considered under multidisciplinary monitoring. However, maternal and fetal complications with moderate to severe pulmonary hypertension significantly increase. Hence, it is essential to evaluate pregnancy risk and terminate it in time.

Towards a clinical consensus on the management of pregnancy and birth after laparoscopic and open myomectomy: A survey of obstetricians and gynaecologists

OBJECTIVES

The primary aim was to assess if a clinical consensus regarding the management of pregnancy post myomectomy existed amongst consultant obstetricians and gynaecologists. Secondary objectives were to evaluate factors which influence the clinician's decision making in this group of women.

STUDY DESIGN

Electronic survey sent to all consultants working in the North Central and East London deanery, Kent Surrey and Sussex deanery and Imperial NHS Trust to assess opinions on mode of birth post myomectomy, intervals advised to pregnancy post myomectomy, factors influencing the management of delivery in the scarred uterus post myomectomy, opinions on induction of labour and questions relating to operative notes.

RESULTS

209 consultant responses received between 07/03/2022-07/05/2022 (44% response rate); 77% (161/209) practicing obstetricians and gynaecologists, 10% (21/109) pure gynaecologists and 13% (27/209) pure obstetricians. The majority would support a vaginal birth after open myomectomy (75%) and laparoscopic myomectomy (79%). No consensus was found as to the optimal time interval between myomectomy and pregnancy. Higher frequency of performing myomectomy and a greater level of experience were significantly associated with a shorter interval to pregnancy advised. The most important operative factors influencing decision to support trial of labour post myomectomy were breach of uterine cavity; location of fibroids removed and number of incisions on the uterus. 77% believe women should be given a choice regarding mode of delivery post myomectomy in a similar way to previous LSCS. 82.8% would support enrolment of patients into a prospective trial to investigate delivery post myomectomy.

CONCLUSIONS

We present a comprehensive survey of clinician opinions on pregnancy post myomectomy demonstrating that the majority of consultant obstetricians and gynaecologists sampled would support vaginal birth post myomectomy; counselling patients in a similar way to VBAC; a standardised myomectomy operation note and enrolment of patients in a future prospective trial. Wide variation in opinion regarding interval to pregnancy post myomectomy has been highlighted. We believe this information will facilitate counselling discussions and empower women with subsequent pregnancies after myomectomy to make an informed decision on mode of birth post myomectomy.

"She was there all the time". A qualitative study exploring how women at higher risk for preterm birth experience midwifery continuity of care

PROBLEM

There is a paucity of research on experiences and views of women at higher risk of preterm birth of midwifery continuity of care.

BACKGROUND

Midwifery continuity of care (MCoC) has been associated with improved maternal outcomes and with lower levels of preterm births and stillbirths. The majority of MCoC studies have focused on women without risk factors and little has been published on women with obstetric complexities. The aim of this study is to explore the views and experiences of women identified as a higher risk of preterm birth who have had continuity of care from midwives.

DESIGN

Face-to-face, semi-structured interviews with 16 women identified as at increased risk of preterm birth and experienced continuity of midwifery care across pregnancy, birth and the postnatal period. Care had been provided by the pilot intervention group for the pilot study of midwifery practice in preterm birth including women's experiences (POPPIE) trial.

FINDINGS

Women valued continuity of midwifery care across the care pathway and described the reassurance provided by having 24 h a day, seven days a week access to known midwives. Consistency of care, advocacy and accessibility to the team were described as the main factors contributing to their feelings of safety and control.

KEY CONCLUSIONS

Recognising that known midwives were 'there all the time' made women feel listened to and actively involved in clinical decision making, which contributed to women feeling less stressed and anxious during their pregnancy, birth and early parenthood. When developing MCoC models for women with obstetric complexities: access, advocacy and time should be embedded to ensure women can build trusting relationships and reduce anxiety levels.

Pulmonary hypertension in pregnancy and its effects on the fetus

Pulmonary hypertension (PH) is an important and potentially lethal diagnosis for pregnant patients. Although pregnancy is usually contraindicated in this condition and there is no standard algorithm for the treatment of pregnant patients with PH, studies in recent years have shown improvement in maternal outcomes for those with PH. Many factors have likely contributed to the improved outcomes, including earlier treatment by multidisciplinary teams. Pregnant patients with PH require specialized management throughout pregnancy, especially in the early post-partum period. Echocardiography is an important diagnostic tool to follow cardiac function in these patients. PH and its treatment during pregnancy has significant implications on maternal as well as fetal outcomes. In this review, PH management during pregnancy and the fetal implications are summarized.

Commercial Air And High-Altitude Travel by Pregnant Women: A scientific review commissioned by the European Board and College of Obstetrics and Gynaecology (EBCOG)

Air travel and long distance travel may have adverse effect on the pregnancy-induced physiology and these effects are more marked among those with pre-existing medical conditions. There are significantly increased risks of deep venous thrombosis, inflight transmission of infections, preterm labour, and other significant obstetric and medical complications that may be exacerbated by the flight and may require emergency care. Transient changes in cardiotocographic tracings during third trimester of pregnancy have been reported following air travel. It has been suggested that pregnant members of the flight crew may be at a slightly higher risk of spontaneous miscarriages. There are no contra-indications for healthy pregnant women on air travel. Those with underlying medical conditions should only embark on long distance travel following consultation with their obstetrician. Pregnant women should be advised to familiarise themselves with the healthcare system in the country/region they will be visiting and draw up an emergency plan of how they will contact the healthcare system at their destination.

Referral care for high-risk pregnant women in rural Rajasthan, India: a qualitative analysis of barriers and facilitators

Objective

To qualitatively assess the barriers and facilitators to uptake of referral services amongst high-risk pregnant women in rural Rajasthan.

Methods

A purposive sample of pregnant women with high-risk conditions requiring referral follow-up care (severe hypertension, moderate anemia, and severe anemia) were considered for inclusion. In-depth individual interviews were conducted in the local dialect, Mewari. Interviews were transcribed, coded, and organized for thematic generation as per the analytical framework described in the socio-ecological model.

Results

19 high risk pregnant women of low socioeconomic backgrounds across 15 villages were interviewed. Barriers to referral care included lack of transportation, household responsibilities, and limited awareness, education, and social support. The most prominent barrier was lack of accompaniment to the referral center by a family member or health worker. Facilitators included available husbands, engaged heath workers, supportive neighbors, and other female family members who shared past experiences.

Conclusions

Social support at the interpersonal and community level was key to overcoming referral care barriers faced by high-risk pregnant women in rural Rajasthan. Interventions that enhance social support may improve uptake of referral care services by high-risk pregnant women.

Impact of childbirth policy changes on obstetric workload over a 13-year period in a regional referral center in China - implications on service provision planning

BACKGROUND

We aimed to appraise the impact of the changing national childbirth policy since 2002, currently allowing two children per family, on obstetric workload in a regional referral center in China.

METHODS

In a retrospective cohort study, temporal changes were examined in relation with maternal demographics, incidence of women with high risk pregnancies and resource statistics in our hospital in managing singleton viable pregnancies (birth from 28 weeks gestational age onwards) for the period 2005-2017.

RESULTS

During this 13-year period, the number of singleton livebirths from 28 weeks gestational age onwards was 49,479. Annual numbers of births increased from 1,941 to 2005 to 5,777 in 2017. There were concomitant and significant increases in the incidence of multiparous women (10.6-50.8 %), of age ≥35 years (6.5-24.3 %), with prior caesarean Sec. (2.6-23.6 %), with ≥3 previous pregnancy terminations (1.0-4.9 %), with pre-gestational diabetes (0.2-0.9 %), and with chronic hypertension (0.2-1.2 %). There were associated increases in beds and staff complement and reduced average hospital stay. Nevertheless, while the workload of medical staff remained stable with increasing staff complement, that of midwives increased significantly as reflected by the total births: midwife ratio which increased from 194.1:1 to 320.9:1 (p < 0.001).

CONCLUSIONS

In our hospital, progressively increasing numbers of annual births in combination with an increased incidence of women with high risk pregnancies took place following the revised national childbirth policy. Only the increase in medical and nursing, but not midwifery, staff was commensurate with workload. Remedial measures are urgently required before the anticipated progressive increase in care demand would overwhelm maternity care with potentially disastrous consequences.

Pregnancy and delivery in a patient with a Fontan circulation and primary ciliary dyskinesia: A case report

A patient had primary ciliary dyskinesia with a complex cardiac malformation. As a child, she had benefited from a Fontan surgery to maintain a proper cardiac function. In such patients, whether it is safe to become pregnant is controversial. This case illustrates the possibility of carrying a pregnancy to term and providing a vaginal birth if a rigorous preconception consultation is performed to ensure care by a multidisciplinary specialized team, and the patient is properly informed of the risks.

The Effect of Midwife-led Psycho-Education on Parental Stress, Postpartum Depression and Parental Competency in High Risk Pregnancy Women: A Randomized Controlled Trial

Introduction: Women with high-risk pregnancy are at increased risk of depression and anxiety during pregnancy, as well as a less favorable parent-infant interaction. This study aimed to investigate the effect of midwife-led psycho-education intervention on parental stress, competency, and postpartum depression in nulliparous women hospitalized with high-risk pregnancy.

Methods: This randomized controlled trial was carried out on 66 nulliparous women admitted to the high-risk pregnancy ward of Kamali Hospital, Karaj, Iran. Using convenient sampling method, the mothers were randomly assigned to control and intervention groups. In addition to routine care, the intervention group received four sessions of midwife-led psycho-education intervention in two group sessions in pregnancy and two individual sessions immediately after delivery. The parental stress, parental competency, and postpartum depression questionnaires were used for data collection before, after, and one month after the intervention. Data were analyzed using SPSS software ver. 13.0. Repeated-measures ANOVA test was used for comparing the mean scores of parenting stress, parental competency, and depression between and within both study groups before, after, and one month after delivery.

Results: While postpartum depression and parental stress decreased in intervention group, parental competency increased.

Conclusion: Our findings indicated that midwife-led psycho-education was effective on parental stress, competency, and postpartum depression in high-risk pregnancy mothers. Accordingly, prenatal distress in high-risk pregnancies should be assessed routinely.

Prediction of hypertension in pregnancy in high risk women using maternal factors and serial placental profile in second and third trimester

INTRODUCTION

To evaluate the role of placental profile markers in second and third trimester of pregnancy in predicting hypertensive disorders of pregnancy (HDP) in women at high risk of preeclampsia.

METHOD

Women who were at high risk of preeclampsia underwent βhCG, ultrasound assessment of placental length, thickness and its ratio, uterine artery Doppler at 20-24 weeks and 28-32 weeks of gestation, the outcome at delivery was noted. Those who developed HDP were cases and those with normal outcome were controls. The placental profile markers among cases and controls were compared.

RESULTS

Hypertensive disorders of pregnancy was seen in 72/160 (45%) high risk women The serum β hCG levels at 20-24 weeks (p = 0.001) and 28-32 weeks (p = 0.018) was significantly high in women who had preeclampsia. Placental thickness was found to be less in among all subgroups of HDP, for preeclampsia, it was significantly low at 20-24 weeks (AUC- 0.743; sensitivity- 75%, specificity- 66.3%) and 28 weeks (AUC -0.764, sensitivity - 75.0% specificity - 78.7%). Uterine artery S/D ratio was considerable high in women with chronic hypertension (AUC -0.765), gestational hypertension (AUC -0.771) and preeclampsia (AUC -0.726) at 20-24 weeks. In preeclampsia group, uterine artery PI was highest and the best marker at 20-24 weeks (AUC -0.935, sensitivity - 100.0%, specificity - 87.6%).

DISCUSSION

The placental profile markers may be used to provide closer follow up in high risk pregnancies with abnormal placental profile levels, while less intense follow up in those with normal levels, thus channelizing the resources.

Pregnancy vs. paycheck: a qualitative study of patient's experience with employment during pregnancy at high risk for preterm birth

Background

Pregnant women with a history of preterm birth are at risk for recurrence, often requiring frequent prenatal visits for close monitoring and/or preventive therapies. Employment demands can limit uptake and adherence to recommended monitoring and preterm birth prevention therapies.

Method

We conducted a qualitative descriptive study using in-depth interviews (IDIs) of pregnant women with a history of preterm birth. IDIs were conducted by trained qualitative interviewers following a semi-structured interview guide focused on uncovering barriers and facilitators to initiation of prenatal care, including relevant employment experiences, and soliciting potential interventions to improve prompt prenatal care initiation. The IDIs were analyzed via applied thematic analysis.

Results

We described the interview findings that address women’s employment experiences. The current analysis includes 27 women who are majority self-described as non-Hispanic Black (74%) and publically insured (70%). Participants were employed in a range of professions; food services, childcare and retail were the most common occupations. Participants described multiple ways that being pregnant impacted their earning potential, ranging from voluntary work-hour reduction, involuntary duty hour reductions by employers, truncated promotions, and termination of employment. Participants also shared varying experiences with workplace accommodations to their work environment and job duties based on their pregnancy. Some of these accommodations were initiated by a collaborative employee/employer discussion, others were initiated by the employer’s perception of safe working conditions in pregnancy, and some accommodations were based on medical recommendations. Participants described supportive and unsupportive employer reactions to requests for accommodations.

Conclusions

Our findings provide novel insights into women’s experiences balancing a pregnancy at increased risk for preterm birth with employment obligations. While many women reported positive experiences, the most striking insights came from women who described negative situations that ranged from challenging to potentially unlawful. Many of the findings suggest profound misunderstandings likely exist at the patient, employer and clinical provider level about the laws surrounding employment in pregnancy, safe employment responsibilities during pregnancy, and the range of creative accommodations that often allow for continued workplace productivity even during high risk pregnancy.

Eosinophilic gastroenteritis in pregnancy: A review of the literature

Eosinophilic gastroenteritis (EGE) is an uncommon and heterogeneous disease characterized by eosinophilic infiltration of the gastrointestinal tract. There are very few reports in literature describing pregnancies in EGE patients, and no review has ever been published. We found a total of 12 cases including one that occurred in our clinic. In 5 out of 12 cases, EGE was diagnosed after delivery and pregnancies are described as uneventful. Of the 5 patients who already had a diagnosis of EGE before pregnancy, only one registered an improvement of symptoms during gestation, while the rest had no significant changes, and their pregnancies needed to be monitored as high risk. Regarding pregnancy complications, only two patients had a pre-term delivery. Both patients had not only EGE, but a remarkable obstetrical history, that could slightly complicate the interpretation of the events that occurred in their pregnancies. More studies are necessary to demonstrate if EGE is connected with pre-term onset of labor. It's not easy to define the reasons of some patient's pre term labor, and we could suppose that a combination of different mechanisms leads to this condition of breakdown of maternal-fetal tolerance. Nevertheless, we know that spontaneous preterm labor is a syndrome attributable to multiple pathologic processes and most of them are yet to be understood. However, we cannot exclude that EGE is related to late preterm delivery. We hope that this review will provide some measures of guidance to those clinicians who must satisfy the questions of young female patients diagnosed with EGE and wishing for a pregnancy.

Home-based telemonitoring versus hospital admission in high risk pregnancies: a qualitative study on women's experiences

BACKGROUND

Hospital admission during pregnancy complications is considered to be an event of significant impact. Besides conventional in-clinic maternal and fetal monitoring, recent technologies enable home-based telemonitoring with self-measurements in high risk pregnancy. This study is part of a feasibility pilot to explore the usability and acceptability of telemonitoring and aims to gain insight in the experiences and preferences of high risk pregnant women concerning the novel strategy of telemonitoring, opposed to women who were hospitalized in pregnancy.

METHODS

Using secured Facebook Groups, we conducted four online focus groups: two focus groups with women who were admitted during pregnancy (n = 11) and two with women who received home telemonitoring in the pilot phase (n = 11). The qualitative data were analyzed thematically.

RESULTS

Four major themes emerged from both participant groups: [1] care experience, [2] emotions regarding pregnancy, [3] privacy and [4] impact on daily life. Different views were reported on all four themes, resulting in a direct comparison of experiences during hospitalization and telemonitoring. Most admitted patients reported a growing sense of boredom and anxiety during their clinical admission. Lack of privacy on ward was a great concern, as it affected their contact with hospital staff and family. This issue was not reported amongst telemonitored women. These participants still felt like a patient at times but responded that the comfort of their own home and bed was pleasant. Only a minority of telemonitored participants reported being anxious at times at home, while not having a physician or nurse nearby. Being at home resulted in less travel time for partners or family for hospital visits, which had its positive effects on family life.

CONCLUSIONS

Telemonitoring of a high-risk pregnancy provides an innovative manner to monitor fetal and maternal condition from home. Compared to the experiences of hospital admission in high risk pregnancy, it allows women to be in a comforting and private environment during an anxious time in their lives. As future studies should further investigate the safety and cost effectiveness of this novel strategy, women's views on the preference of telemonitoring need to be taken into consideration.

Utility of Lupus Anticoagulant Assays (APTT-LA, KCT, DPT and DRVVT) in Detection of Antiphospholipid Syndrome (APS) in High Risk Pregnancy Cases

Routine investigation for recurrent pregnancy loss includes measurement of antiphospholipid antibodies. The lupus anticoagulant has long been associated with increased risks for thrombosis and adverse obstetric outcomes. But there are some disadvantages with lupus anticoagulant (LAC) tests which includes varied sensitivity of different clot based assays. ISTH recommends only 2 assays (preferably DRVVT and APTT-LA) for the identification of lupus anticoagulant but there are some studies which don't support this contention. Our study analyzed 526 samples from high risk pregnancy cases for APLA by all four LAC tests from tertiary centre of northern India. Among all the cases studies 65 cases were positive for lupus anticoagulant 25 of this became negative after 12 weeks. Among the 40 repeated positive assays, dRVVT could able to diagnose 36 cases followed by APTT-LA which could able to diagnose 28 cases, while KCT could able to diagnose 23 cases and dPT could able to diagnose only 14 cases. There were 12 cases in whom all lupus assays were positive. Our study thus concluded that DRVVT was the most sensitive followed by APPT-LA, KCT, dPT. The combination of dRVVT with APTT-LA or KCT appeared to be superior to other combinations. No individual test per se is 100% sensitive for the diagnosis of APLA in high risk pregnancy cases. Further results confirmed that repeated LAC result is required even in a high-risk setting. Positive LAC assay in majority were not associated with exclusively recurrent pregnancy loss but were associated with sporadic stillbirth and thrombosis.

Antepartum Risk Assessment for Pregnant Women Visiting a Tertiary Care University Teaching Hospital in Southern India

AIM

The study was conducted to assess the prevalence of high-risk pregnancy (HRP) cases among pregnant women visiting the Prabhakar Kore Hospital (PKH) at Belagavi, Karnataka for antenatal care (ANC) and determination of the level of risk in the identified cases.

MATERIALS & METHODS

Data were collected as a part of a screening procedure of a nutrition supplement clinical trial on pregnant women [Study title: Maternal DHA Supplementation and offspring Neurodevelopment in India (DHANI)]. ANC case records including detailed notes on medical and obstetric history, physical examination, laboratory investigations of pregnant women with ≤ 20 weeks of gestational age were screened for known risk factors.

RESULTS

A total of 11,686 new cases were registered for ANC between June 2016 through August 2017. Of these, 3379 (<20 weeks gestation) were screened out of 428 pregnant women, 12.6% pregnant women were found to be at risk, 40.2% (n=172) fell in the high-risk category. Most commonly reported risk factors were thyroid disorders (27.3%, hypothyroidism 17.3%; hyperthyroidism 10%), gestational diabetes (16.1%), bad obstetric history (12.6%) and anaemia (10.7%).

CONCLUSION

Early identification of these at-risk mothers through a simple, practical, reliable and customized risk scoring schedule can ensure interventions either to control the risk causing factor or delivery of timely and appropriate care as and when needed.

CLINICAL SIGNIFICANCE

Considering the disproportionate burden that high risk pregnancies pose on higher mortality rates and compromised quality of life for the cases which survive, early identification of these high risk cases (12.6% identified in this study) can have a significant impact on maternal and child health. The population negatively affected by at-risk pregnancies is only expected to increase in the near future in light of the rising trend of its known risk factors such as high blood pressure, diabetes, or being HIV-positive.

Clinical features and outcomes of pregnancies complicated by pre-ecplampsia necessitating in-utero transfer

OBJECTIVES

Pre-eclampsia (PE) is associated with significant risks of adverse perinatal outcomes, often necessitating transfer to a higher level of care for specialist perinatal management. In Victoria, Australia, the Paediatric Infant Perinatal Emergency Retrieval (PIPER) coordinates in-utero transfers of high-risk pregnancies. Our objectives were to report the clinical features and outcomes of women referred to PIPER with a primary diagnosis of PE, and subsequently transferred in-utero.

STUDY DESIGN

A retrospective audit of consecutive pregnancies referred to PIPER in 2013-2014 with a primary diagnosis of pre-eclampsia, ≥20 weeks' gestation and transferred in-utero.

MAIN OUTCOME MEASURES

Severity of disease, gestational age, transfer details and outcome until 7 days post transfer.

RESULTS

Over two years, 244 women were referred to PIPER with PE; 199 (82%) were subsequently transferred in-utero. Severe PE was diagnosed in 146 (73%) women. Overall, 64% presented 'early' (<32 weeks' gestation). Only 6% were ≥37 weeks. All but 2 women <32 weeks were transferred to a tertiary perinatal centre, compared with 39% of women ≥32 weeks. Within 7 days, 153/199 (77%) delivered, 10% remained in-patients and 12.5% were discharged. There were 165 livebirths and 3 stillbirths, with a mean gestational age of 30.7 weeks (SD 3.3 weeks). Twenty-nine women required high dependency or intensive care admission. No maternal deaths were reported.

CONCLUSION

Women referred to PIPER predominantly presented with early onset, severe PE and most delivered within 7 days of transfer. Data from this study provides important information for obstetric service planning in Victoria and comparable regions.

Efficacy Of 17- Α-Hydroxy-Progestrone In Prevention Of Preterm Labour In High Risk Pregnant Women

BACKGROUND

Preterm delivery (before 37 completed weeks of gestation) is a major determinant of infant mortality. The objective of study was to determine the efficacy of 17-alpha hydroxyprogesterone in preventing delivery before 37 weeks of gestation in high risk women.

METHODS

This study, a randomized controlled trial was conducted in Obstetrics OPD, observing all scientific and ethical protocols. The women with less than 20 weeks gestation and with a past history of preterm delivery were included. A total of 132 women fulfilled the study requirements. Two groups made were as follows: Group A (Treatment group received intramuscular 17-alpha hydroxy-progesterone) and Group B served as control (The control group revived intramuscular Neurobion). A total of 66 women were assigned to each group. The data was recorded on a specially designed proforma for statistical analysis and comparison following the standard procedure.

RESULTS

The criterion was strictly observed. The results showed a statistically significant (p<0.01) difference between group A as compared to group B.

CONCLUSIONS

17-α- Hydroxyprogesterone was found to be an effective drug in preventing delivery before 37 weeks in women at risk.

Dilated Cardiomyopathy in Pregnancy: Outcomes From an Australian Tertiary Centre for Maternal Medicine and Review of the Current Literature

BACKGROUND

Peripartum cardiomyopathy is associated with significant risks of decline in left ventricular function and adverse maternal and fetal outcome in subsequent pregnancy. The risks of pregnancy in women with dilated cardiomyopathy are unclear. We aimed to assess the outcome of pregnancy in women with dilated cardiomyopathy seen at our institution and to review the literature on this subject.

METHODS

A retrospective audit of the outcomes of 14 pregnancies to 12 women with dilated cardiomyopathy.

RESULTS

There were no cardiac events and no woman had a decline in left ventricular function during pregnancy. There was a high rate of prematurity and adverse fetal outcome related to this, including four neonatal deaths.

CONCLUSION

Maternal outcomes in this small series were satisfactory though only three women had moderate-severe left ventricular dysfunction at baseline. There was a high rate of premature delivery and adverse neonatal outcome.

Specialist antenatal clinics for women at high risk of preterm birth: a systematic review of qualitative and quantitative research

Background

Preterm birth (PTB) is the leading cause of perinatal morbidity and mortality. Women with previous prenatal loss are at higher risk of preterm birth. A specialist antenatal clinic is considered as one approach to improve maternity and pregnancy outcomes.

Methods

A systematic review of quantitative, qualitative and mixed method studies conducted on women at high risk of preterm birth (PTB). The review primary outcomes were to report on the specialist antenatal clinics effect in preventing or reducing preterm birth, perinatal mortality and morbidity and women’s perceptions and experiences of a specialist clinic whether compared or not compared with standard antenatal care. Other secondary maternal, infant and economic outcomes were also determined. A comprehensive search strategy was carried out in English within electronic databases as far back as 1980. The reviewers selected studies, assessed the quality, and extracted data independently. Results were summarized and tabulated.

Results

Eleven studies fully met the review inclusion criteria, ten were quantitative design studies and only one was a qualitative design study. No mixed method design study was included in the review. All were published after 1989, seven were conducted in the USA and four in the UK. Results from five good to low quality randomised controlled trials (RCTs), all conducted before 1990, did not illustrate the efficacy of the clinic in reducing preterm birth. Whereas results from more recent low quality cohort studies showed some positive neonatal outcomes. Themes from one good quality qualitative study reflected on the emotional and psychological need to reduce anxiety and stress of women referred to such a clinic. Women expressed their negative emotional responses at being labelled as high risk and positive responses to being assessed and treated in the clinic. Women also reported that their partners were struggling to cope emotionally.

Conclusions

Findings from this review were mixed. Evidence from cohort studies indicated a specialist clinic may be a means of predicting or preventing preterm birth. Testing this in a randomised controlled trial is desirable, though may be hard to achieve due to the growing focus of such clinics on managing women at high risk of preterm birth. Ongoing research has to recognize women’s experiences and perceptions of such a clinic. Further clarification of the optimal referral route and a clear and standardized management and cost economic evaluation plan are also required. Fathers support and experience of PTB clinics should also be included in further research.

[Maternal metabolic diseases related to pre-pregnancy overweight and obesity in mexican women with high risk pregnancy]

INTRODUCTION

Pre-pregnancy obesity has been proposed as a risk factor related to gestational diabetes and hypertensive disorders during pregnancy.

OBJECTIVES

Identify pregnancy related diseases associated with pre-pregnancy obesity as a risk factor ina high risk preganancy patient population.

METHODS

600 patients whose pre-pregnancy obesity had been assessed as a high risk factor were included in the study. The means, standard deviation, median, interquartile intervals, Pearson and Spearman correlation and logistic regression to estimate risk with the odds ratio and 95% confidence intervals were calculated.

RESULTS

The mean pre-pregnancy body mass index was 29.59 ± 6.42 kg/m². The mean for recommended pregnancy weight gain was 2.31 ± 1.03 kg, but the mean of real weight gain was 8.91 ± 6.84 kg. A significant correlation between pre-pregnancy obesity and family history of diabetes mellitus (p=0.000), systemic hypertension (p=0.003), cardiac diseases (p=0.000), dyslipidemia (p=0.000) and obesity (p=0.000) was identified. Pre-pregnancy obesity was identified as a risk factor for the development of gestational diabetes (OR: 1.95; IC95%: 1.39 to 2.76; p=0.000) in this kind of patient.

DISCUSSION AND CONCLUSION

75% of high risk pregnancy women in a high specialty hospital in West Mexico are overweight or obese when they become pregnant. These are risk factors in the development of gestational diabetes.

Pregnancy in Hypertrophic Cardiomyopathy with Severe Left Ventricular Outflow Tract Obstruction

Hypertrophic obstructive cardiomyopathy (HOCM) patients with severe left ventricular outflow tract (LVOT) obstruction (those with a gradient of > 100 mm Hg) are at the highest risk of hemodynamic deterioration during pregnancy. Complications of HOCM include sudden cardiac death, heart failure, and arrhythmias. Physiological changes during pregnancy may induce these complications, affecting maternal and fetal health conditions. Therefore, close monitoring with appropriate management is essential for the well-being of both mother and fetus. We report on the case of a 27-year-old female patient with severe LVOT obstruction HOCM, pressure gradient (PG) of 125 mm Hg at resting, and 152 mm Hg induced by the Valsalva maneuver at 34 weeks gestation. This case showed how close monitoring using echocardiography and proper management during the course of pregnancy resulted in successful delivery in the patient with extremely high PG HOCM.

Perspectives and Challenges of HMIS Officials in the Implementation of Health Management Information System (HMIS) with Reference to Maternal Health Services in Assam

INTRODUCTION

Health Management Information System (HMIS) is one of the important components of National Rural Health Mission (NRHM). The web portal of HMIS was launched by the Ministry of Health and Family Welfare (MOHFW), Govt. of India (GOI) in 21(st) Oct. 2008 to enable capturing of public health data from both public and private institutions in rural and urban areas across the country.

AIM

The aim of the study was to assess the quality perspectives and challenges among HMIS officials in implementing HMIS at their respective levels, i.e. district and block level.

MATERIALS AND METHODS

We conducted a pilot qualitative study in two districts of Assam. HMIS officials working at district and block level were interviewed in-depth with the help of a semi-structured interview schedule which lasted from May to July 2014.

RESULTS

Both HMIS and MCTS (Mother and Child Tracking System) formats were considered useful, by the HMIS officials, for data collection, planning at various levels, tracking maternal and neonatal deaths, institutional deliveries. HMIS officials reported that MCTS is useful for monitoring individual health status especially the status of the mother and child and HMIS being helpful as a health facility monitoring tool.

CONCLUSION

The study used a small sample size, hence similar type of studies are required with large sample size to understand the perspectives and challenges of HMIS officials in the implementation of HMIS.

Risk perception and choice of place of birth in women with high risk pregnancies: A qualitative study

Objective To examine the perception of risk among a group of women with high risk pregnancies who were either planning to give birth in hospital, or at home despite medical advice to the contrary. The intention was to consider differences and similarities between the groups to examine how perception of risk relates to choice of place of birth. Design Qualitative study using semi-structured interviews. Setting Maternity department in a hospital in South East England. Participants Twenty-six women with high risk pregnancies, at least 32 weeks pregnant. Half were planning hospital births and half homebirths. Measurements and findings Semi-structured interviews to investigate women's understanding and assessment of risk. Results were analysed using thematic analysis. Five themes emerged: understanding of situation; judgement of risk; reassuring factors; impact of risk; and coping with risk. Women from both groups had some understanding of the implications of their medical/obstetric conditions. They displayed concerns about their babies' wellbeing. Women planning homebirths assessed their risks as lower and expressed less concerns than women planning hospital births. Women planning hospital births more frequently described following professional advice. Key conclusions Risk perception is individual and subjective. Women with high risk pregnancies who plan to give birth at home perceive risk differently to women who plan hospital births. Implications for practice Healthcare professionals working with women with high risk pregnancies should be aware of the potential for differences in definitions and perceptions of risk within this group.

Hemorrhagic heterotopic pregnancy in a setting of prior tubal ligation and re-anastomosis

Heterotopic pregnancy is the occurrence of simultaneous intrauterine and extrauterine pregnancies. Heterotopic pregnancy most commonly occurs during the first trimester of pregnancy in women who have significant risk factors including assisted reproductive therapy, prior ectopic pregnancy, and prior pelvic surgery or pelvic inflammatory disease. Although rare, heterotopic pregnancy must be recognized using ultrasound so as to provide appropriate treatment to the extrauterine pregnancy with the goal of preserving the intrauterine pregnancy. The case presented describes a patient with a pathologically proven (figure 8A and 8B), surgically treated 1st trimester heterotopic pregnancy.

A Prospective Study of Placental Growth Factor Assay as a Novel Biomarker in Predicting Early-Onset Preeclampsia in High-Risk Patients

INTRODUCTION

Preeclampsia is a leading cause of maternal and perinatal mortality and morbidity, but signs and symptoms are non-specific and may vary. The root cause is imbalance of circulating angiogenic factors of placental (syncytiotrophoblast) origin, with consequent low levels of placental growth factor (PlGF) which may aid in diagnosis and prediction of disease.

AIMS AND OBJECTIVES

To study the incidence of women at risk of developing early-onset preeclampsia by plasma placental growth factor biomarker assay in high-risk patients, to assess the maternal outcome in patients with PlGF values below cutoff for presenting gestational age, to calculate sensitivity, specificity, positive predictive value and negative predictive value of PlGF assay in predicting preeclampsia and to conclude whether PlGF biomarker assay can be an effective screening test in high-risk patients for prediction of early-onset preeclampsia.

MATERIALS AND METHODS

The study was carried out in the Department of Obstetrics and Gynecology at a tertiary care center. It is a prospective study, and study period extended from April 2012 to October 2013. One hundred pregnant women with 20- to 34-week gestational age with possible high risk of developing preeclampsia attending the antenatal clinics and high-risk OPDs were screened in the present study after explaining the nature of the study. PLGF concentration was quantitated using plasma and processed in Triage kit device (fluorescence immunoassay device). PLGF concentration was categorized against a specific range for specific gestation, and values below the range or <12 pg/ml were considered screened positives. The cases were followed up till delivery.

RESULTS

Twenty-two cases were screened positive, of which 20 developed preeclampsia with a strong positive prediction value of more than 90 %.

CONCLUSION

PLGF is a strong predictor and a useful assay for early-onset preeclampsia.

How women with high risk pregnancies use lay information when considering place of birth: A qualitative study

INTRODUCTION

Where to give birth is a key decision in pregnancy. Women use information from family, friends and other sources besides healthcare professionals when contemplating this decision. This study explored women's use of lay information during high risk pregnancies in order to examine differences and similarities in the use of information in relation to planned place of birth. Half the participants were planning hospital births and half were planning to give birth at home.

METHODS

A qualitative study using semi-structured interviews set in a hospital maternity department in South East England. Twenty-six participants with high risk pregnancies, at least 32 weeks pregnant. Results were analysed using thematic analysis.

RESULTS

Three themes emerged: approaches to research - how much information women chose to seek out and from which sources; selection of sources - how women decided which sources they considered reliable; and unhelpful research - information they considered unhelpful. Women planning homebirths undertook more research than women planning to give birth in hospital and were more likely to seek out alternative sources of information. Women from both groups referred to deliberately seeking out sources of information which reflected their own values and so did not challenge their decisions.

CONCLUSIONS

There are similarities and differences in the use of lay information between women who plan to give birth in hospital and those who plan homebirths. Professionals working with women with high risk pregnancies should consider these factors when interacting with these women.

Trisomy Xp and partial tetrasomy Xq resulting from gain of a rearranged X chromosome in a female fetus: pathogenic or not?

Cytogenetic analysis of chorionic villous sampling revealed a mosaic karyotype with gain of a rearranged X chromosome. Microarray and additional studies indicated that the rearranged X carried an inverted duplication, a deletion and a satellited Xqter. Gain of this rearranged X was confirmed by follow-up amniocentesis and postnatal cord blood sample. A full-term infant girl was delivered and showed normal physical findings at both birth and 21-month follow-up examinations. Late replication studies demonstrated that the rearranged X was inactivated in all abnormal cells analyzed. Skewed X-inactivation may suppress the potentially deleterious effects of genomic imbalance; however, gain of X chromosomes, particularly rearranged X chromosomes, often presents challenges for prenatal genetic counseling. The gradation of clinical phenotype severity generally correlates with the number of additional X chromosomes. However, the X chromosome regions responsible for the abnormal phenotypes are poorly understood. This case will further elucidate the phenotypic effects of X inactivation and X chromosome abnormalities.

A metasynthesis of risk perception in women with high risk pregnancies

INTRODUCTION

risk perception in women with high risk pregnancies affects their decisions about perinatal care and is of interest to anyone involved in the care of pregnant women. This paper provides a metasynthesis of qualitative studies of risk perception in women with high risk pregnancies.

METHODS

a systematic search of eight electronic databases was conducted. Additional papers were obtained through searching references of identified articles. Six studies were identified that reported qualitative research into risk perception in relation to high risk pregnancy. A metasynthesis was developed to describe and interpret the studies.

FINDINGS

the synthesis resulted in the identification of five themes: determinants of risk perception; not seeing it the way others do; normality versus risk; if the infant is ok, I׳m ok; managing risk.

CONCLUSIONS

this metasynthesis suggests women at high risk during pregnancy use multiple sources of information to determine their risk status. It shows women are aware of the risks posed by their pregnancies but do not perceive risk in the same way as healthcare professionals. They will take steps to ensure the health of themselves and their infants but these may not include following all medical recommendations.

Obstetric medical emergency teams are a step forward in maternal safety!

Background and Aim:

The medical emergency team (MET) system was introduced successfully worldwide. With the exception of a few research publications, most of the described teams are based on patients’ medical rather than obstetric management. The objective of this study was to review literature on the outcome of obstetric MET implementation.

Materials and Methods:

Systematic review has been done through searching MEDLINE, the Cochrane Library, relevant articles references, and contact with experts. The author and one other researcher independently selected literature on the establishment or implementation of obstetric MET. There were no restrictions on language, sample size, type of publication, or duration of follow up.

Results:

Three publications were identified: Catanzarite et al., Gosman et al., and Skupski et al. They were heterogeneous in terms of the method of implementation and the outcomes discussed. None of them discussed obstetric MET implementation in developing countries.

Conclusion:

In the literature, there is a lack of reporting and probably of implementation of Obstetrics METs. Therefore, there is a need for more standardized experiences and reports on the implementation of various types of Obstetrics METs. We propose here a design for Obstetrics METs to be implemented in developing countries, aiming to reduce maternal mortality and morbidity resulting from obstetric hemorrhage.