Protocol for cost-effectiveness analysis of a randomised trial of mHealth coaching (Bump2Baby and Me) compared with usual care for healthy gestational weight gain and postnatal outcomes in at-risk women and their offspring in the UK, Australia, Ireland and Spain

INTRODUCTION

Gestational diabetes mellitus and overweight are associated with an increased likelihood of complications during birth and for the newborn baby. These complications lead to increased immediate and long-term healthcare costs as well as reduced health and well-being in women and infants. This protocol presents the health economic evaluation to investigate the cost-effectiveness of Bump2Baby and Me (B2B&Me), which is a health coaching intervention delivered via smartphone to women at risk of gestational diabetes.

METHODS AND ANALYSIS

Using data from the B2B&Me randomised controlled trial, this economic evaluation compares costs and health effects between the intervention and control group as an incremental cost-effectiveness ratio. Direct healthcare costs, costs of pharmaceuticals and intervention costs will be included in the analysis, body weight and quality-adjusted life-years for the mother will serve as the effect outcomes. To investigate the long-term cost-effectiveness of the trial, a Markov model will be employed. Deterministic and probabilistic sensitivity analysis will be employed.

ETHICS AND DISSEMINATION

The National Maternity Hospital Human Research and Ethics Committee was the primary approval site (EC18.2020) with approvals from University College Dublin HREC-Sciences (LS-E-20-150-OReilly), Junta de Andalucia CEIM/CEI Provincial de Granada (2087-M1-22), Monash Health HREC (RES-20-0000-892A) and National Health Service Health Research Authority and Health and Care Research Wales (HCRW) (21/WA/0022). The results from the analysis will be disseminated in scientific papers, through conference presentations and through different channels for communication within the project.

TRIAL REGISTRATION NUMBER

ACTRN12620001240932.

The IRELAnD study-investigating the role of early low-dose aspirin in diabetes mellitus: a double-blinded, placebo-controlled, randomized trial

BACKGROUND

Although aspirin therapy is being increasingly advocated with the intention of risk modification for a wide range of pregnancy complications, women with prepregnancy diabetes mellitus are commonly excluded from clinical trials.

OBJECTIVE

The primary aim of this study was to examine the effect of aspirin therapy on a composite measure of adverse perinatal outcome in pregnancies complicated by pregestational diabetes mellitus.

STUDY DESIGN

A double-blinded, placebo-controlled randomized trial was conducted at 6 university-affiliated perinatology centers. Women with type 1 diabetes mellitus or type 2 diabetes mellitus of at least 6 months' duration were randomly allocated to 150-mg daily aspirin or placebo from 11 to 14 weeks' gestation until 36 weeks. Established vascular complications of diabetes mellitus, including chronic hypertension or nephropathy, led to exclusion from the trial. The primary outcome was a composite measure of placental dysfunction (preeclampsia, fetal growth restriction, preterm birth <34 weeks' gestation, or perinatal mortality). The planned sample size was 566 participants to achieve a 35% reduction in the primary outcome, assuming 80% statistical power. Secondary end points included maternal and neonatal outcomes and determination of insulin requirements across gestation. Data were centrally managed using ClinInfo and analyzed using SAS 9.4. The 2 treatment groups were compared using t tests or chi-square tests, as required, and longitudinal data were compared using a repeated-measures analysis.

RESULTS

From February 2020 to September 2022, 191 patients were deemed eligible, 134 of whom were enrolled (67 randomized to aspirin and 67 to placebo) with a retrospective power of 64%. A total of 101 (80%) women had type 1 diabetes mellitus and 25 (20%) had type 2 diabetes mellitus. Reaching the target sample size was limited by the impact of the COVID-19 pandemic. Baseline characteristics were similar between the aspirin and placebo groups. Treatment compliance was very high and similar between groups (97% for aspirin, 94% for placebo). The risk of the composite measure of placental dysfunction did not differ between groups (25% aspirin vs 21% placebo; P=.796). Women in the aspirin group had significantly lower insulin requirements throughout pregnancy compared with the placebo group. Insulin requirements in the aspirin group increased on average from 0.7 units/kg at baseline to 1.1 units/kg by 36 weeks' gestation (an average 83% within-patient increase), and increased from 0.7 units/kg to 1.3 units/kg (a 181% within-patient increase) in the placebo group, over the same gestational period (P=.002). Serial hemoglobin A1c levels were lower in the aspirin group than in the placebo group, although this trend did not reach statistical significance.

CONCLUSION

In this multicenter, double-blinded, placebo-controlled randomized trial, aspirin did not reduce the risk of adverse perinatal outcome in pregnancies complicated by prepregnancy diabetes mellitus. Compared with the placebo group, aspirin-treated patients required significantly less insulin throughout pregnancy, indicating a beneficial effect of aspirin on glycemic control. Aspirin may exert a plausible placenta-mediated effect on pregestational diabetes mellitus that is not limited to its antithrombotic properties.

Dynamic growth changes in fetal growth restriction using serial ultrasonographic biometry and umbilical artery doppler: The multicenter PORTO study

OBJECTIVE

To describe the growth dynamics of fetuses with initial fetal growth restriction (FGR) later outgrowing the 10th centile for estimated fetal weight with respect to perinatal outcomes and maternal factors.

METHODS

A multicenter prospective study recruited 1116 patients for ultrasound surveillance between 2010 and 2012. All pregnancies were growth-restricted singleton gestations between 24 + 0 and 36 + 0 weeks. Biometry and Doppler analysis were carried out, and delivery and adverse perinatal outcomes were recorded.

RESULTS

A total of 193 (17%) fetuses outgrew their diagnosis of initial FGR (surpassed the 10th centile) on their last sonogram before delivery. These fetuses were termed "growers," to compare with the true FGR group. The mothers of "growers" were less likely to be smokers (14% vs 25%, P = 0.0001) or affected by hypertensive pregnancy complications (5.2% vs 15%, P = 0.001). Of the growers, 49 (25%) had an abnormal umbilical artery Doppler; however, in most cases (33/49, 67%), this was a single episode of raised umbilical artery pulsatility index, which subsequently normalized.

CONCLUSION

There were dynamic growth changes in FGR fetuses, with 17% outgrowing their original diagnosis. Positive growth spurts more commonly occurred in healthy mothers. Once a fetus had outgrown the 10th centile, antenatal surveillance could be decreased.

An exploration of prenatal breastfeeding self-efficacy: a scoping review protocol

Objective: To synthesise the evidence on prenatal breastfeeding self-efficacy, including identifying concepts and theoretical frameworks that underpin its development, the evidence on its measurement, interventions used to improve it, and association with breastfeeding outcomes. Background: Breastfeeding self-efficacy is described as a woman's self-belief and confidence in her perceived ability to breastfeed. It is a modifiable measure that is strongly associated with breastfeeding outcomes such as initiation, exclusivity, and duration. Interventions aimed at increasing self-efficacy are often in the postnatal period and have been shown to be effective at improving breastfeeding outcomes. The prenatal period appears to be underexplored in the literature and yet focusing on enhancing it may have the potential for further improvements in self-efficacy and on subsequent breastfeeding outcomes. A comprehensive knowledge synthesis on prenatal breastfeeding self-efficacy is lacking. Methods: The search will include databases across health, psychology, sociology, and the grey literature on breastfeeding guidance. Once the PCC framework (Problem: breastfeeding, Concept: self-efficacy, Context: prenatal period) is met, sources of evidence from any contextual setting will be eligible for inclusion. Limits will not be applied on geographic location or year of publication. The PRISMA-ScR flow diagram of search and study selection will be used to report final figures. Two independent reviewers will perform title and abstract screening and full text review. Data will be charted to provide a logical and descriptive summary of the results that align with the objectives. Conclusion: The results will provide an understanding of what has been done in the space and what gaps exist, informing recommendations for the timing of measurement and the design of prenatal interventions.

Virtual reality in midwifery education: A mixed methods study to assess learning and understanding

BACKGROUND

Virtual reality learning environments (VRLEs) are a potentially valuable learning tool that have recently increased in popularity due to widespread availability and decreased cost. VRLEs can provide an immersive learning environment that increases the understanding of three-dimensional relationships between anatomical structures. However, there is a paucity of evidence in the literature supporting its use within Midwifery education.

OBJECTIVES

To explore the effectiveness of a VRLE as an educational tool in midwifery education.

SETTING

A large University in Ireland, with institutional ethical approval.

PARTICIPANTS

Undergraduate and graduate degree midwifery students.

DESIGN

A descriptive qualitative and quantitative study was carried out. Data collection was carried out between September 2020 and March 2021.

METHODS

Participants underwent a VRLE lesson based on the topic of fetal lie, position, and presentation in pregnancy. A multiple-choice questionnaire was used to quantitatively evaluate knowledge before and immediately after the intervention, and knowledge retention after one week. Qualitative data was collected using open-ended questions in the questionnaire. The primary outcome was a difference in pre- and post-intervention knowledge scores. Data was analysed using repeated measures one-way ANOVA. Qualitative data was analysed using thematic analysis and simple content analysis. All students participated in the quantitative and qualitative components of the study. Secondary outcomes included participant satisfaction and self-confidence in learning which were analysed using thematic analysis. The side effect profile of the virtual reality device was also explored using open-ended questions in the questionnaire.

RESULTS

Forty-one midwifery students participated in the study, with a 100 % participation and response rate. Repeated measures one-way ANOVA revealed no statistically significant differences in knowledge scores pre- and post-intervention. Participants rated high satisfaction and self-confidence scores with regard to the VRLE as a learning modality. Side effects most commonly experienced by participants included dizziness (49 %), disorientation (30 %) and symptoms similar to motion sickness (32 %). The following themes were identified: "Learning in 3D", "The Power of Visual Learning", "The value of Educational Technology", "Learning can be fun and enjoyable".

CONCLUSIONS

This study showed that the VRLE had no impact on knowledge gain, though high levels of satisfaction and self-confidence indicate a positive response to the VRLE. VRLEs are a potentially valuable learning tool to help enhance the student learning experience, promoting increased engagement, satisfaction, and self-confidence with the learning material.

Clinical Outcomes Following a Change in Gestational Diabetes Mellitus Diagnostic Criteria Due to the COVID-19 Pandemic: A Case-Control Study

Background: Due to COVID-19, many centres adopted a change to the diagnosis of GDM. Methods: A case-control study of antenatal patients between 1 April and 30 June in 2019 and 2020 looking at detection rates of GDM, use of medication, obstetric, and fetal outcomes. Results: During COVID-19, the rate of positive GDM tests approximately halved (20% (42/210) in 2020 vs. 42.2% (92/218) in 2019, (p < 0.01)) with higher rates of requirement for insulin at diagnosis (21.4% (2020) vs. 2.2% (2019); p < 0.01), and at term (31% (2020) vs. 5.4% (2019); p < 0.01). and metformin at diagnosis (4.8% (2020) vs. 1.1% (2019); p < 0.01), and at term (14.3% (2020) vs. 7.6% (2019) p < 0.01), with no differences in birth outcomes. Conclusions: There was likely an underdiagnosis of GDM while women at a higher risk of hyperglycaemia were correctly identified. The GTT should be maintained as the gold-standard test where possible, with provisions made for social distancing during testing if required.

Learning Outcomes of Immersive Technologies in Health Care Student Education: Systematic Review of the Literature

BACKGROUND

There is a lack of evidence in the literature regarding the learning outcomes of immersive technologies as educational tools for teaching university-level health care students.

OBJECTIVE

The aim of this review is to assess the learning outcomes of immersive technologies compared with traditional learning modalities with regard to knowledge and the participants' learning experience in medical, midwifery, and nursing preclinical university education.

METHODS

A systematic review was conducted according to the Cochrane Collaboration guidelines. Randomized controlled trials comparing traditional learning methods with virtual, augmented, or mixed reality for the education of medicine, nursing, or midwifery students were evaluated. The identified studies were screened by 2 authors independently. Disagreements were discussed with a third reviewer. The quality of evidence was assessed using the Medical Education Research Study Quality Instrument (MERSQI). The review protocol was registered with PROSPERO (International Prospective Register of Systematic Reviews) in April 2020.

RESULTS

Of 15,627 studies, 29 (0.19%) randomized controlled trials (N=2722 students) were included and evaluated using the MERSQI tool. Knowledge gain was found to be equal when immersive technologies were compared with traditional learning modalities; however, the learning experience increased with immersive technologies. The mean MERSQI score was 12.64 (SD 1.6), the median was 12.50, and the mode was 13.50. Immersive technology was predominantly used to teach clinical skills (15/29, 52%), and virtual reality (22/29, 76%) was the most commonly used form of immersive technology. Knowledge was the primary outcome in 97% (28/29) of studies. Approximately 66% (19/29) of studies used validated instruments and scales to assess secondary learning outcomes, including satisfaction, self-efficacy, engagement, and perceptions of the learning experience. Of the 29 studies, 19 (66%) included medical students (1706/2722, 62.67%), 8 (28%) included nursing students (727/2722, 26.71%), and 2 (7%) included both medical and nursing students (289/2722, 10.62%). There were no studies involving midwifery students. The studies were based on the following disciplines: anatomy, basic clinical skills and history-taking skills, neurology, respiratory medicine, acute medicine, dermatology, communication skills, internal medicine, and emergency medicine.

CONCLUSIONS

Virtual, augmented, and mixed reality play an important role in the education of preclinical medical and nursing university students. When compared with traditional educational modalities, the learning gain is equal with immersive technologies. Learning outcomes such as student satisfaction, self-efficacy, and engagement all increase with the use of immersive technology, suggesting that it is an optimal tool for education.

Obesity in Adults: A 2022 Adapted Clinical Practice Guideline for Ireland

BACKGROUND

This Clinical Practice Guideline (CPG) for the management of obesity in adults in Ireland, adapted from the Canadian CPG, defines obesity as a complex chronic disease characterised by excess or dysfunctional adiposity that impairs health. The guideline reflects substantial advances in the understanding of the determinants, pathophysiology, assessment, and treatment of obesity.

SUMMARY

It shifts the focus of obesity management toward improving patient-centred health outcomes, functional outcomes, and social and economic participation, rather than weight loss alone. It gives recommendations for care that are underpinned by evidence-based principles of chronic disease management; validate patients' lived experiences; move beyond simplistic approaches of "eat less, move more" and address the root drivers of obesity.

KEY MESSAGES

People living with obesity face substantial bias and stigma, which contribute to increased morbidity and mortality independent of body weight. Education is needed for all healthcare professionals in Ireland to address the gap in skills, increase knowledge of evidence-based practice, and eliminate bias and stigma in healthcare settings. We call for people living with obesity in Ireland to have access to evidence-informed care, including medical, medical nutrition therapy, physical activity and physical rehabilitation interventions, psychological interventions, pharmacotherapy, and bariatric surgery. This can be best achieved by resourcing and fully implementing the Model of Care for the Management of Adult Overweight and Obesity. To address health inequalities, we also call for the inclusion of obesity in the Structured Chronic Disease Management Programme and for pharmacotherapy reimbursement, to ensure equal access to treatment based on health-need rather than ability to pay.

Population estimates and determinants of severe maternal thinness in India

OBJECTIVE

To examine prevalence, risk factors, and consequences of maternal severe thinness in India.

METHODS

This mixed methods study analyzed data from the Indian National Family Health Survey (NFHS)-4 (2015-2016) to estimate the prevalence of and risk factors for severe thinness, followed by a desk review of literature from India.

RESULTS

Prevalence of severe thinness (defined by World Health Organization as body mass index [BMI] <16 in adult and BMI for age Z score < -2 SD in adolescents) was higher among pregnant adolescents (4.3%) compared with pregnant adult women (1.9%) and among postpartum adolescent women (6.3%) than postpartum adult women (2.4%) 2-6 months after delivery. Identified research studies showed prevalence of 4%-12% in pregnant women. Only 13/640 districts had at least three cases of severely thin pregnant women; others had lower numbers. Three or more postpartum women aged ≥20 years were severely thin in 32 districts. Among pregnant adolescents, earlier parity increased odds (OR 1.96; 95% CI, 1.18-3.27) of severe thinness. Access to household toilet facility reduced odds (OR 0.72; 95% CI, 0.52-0.99]. Among mothers aged ≥20 years, increasing education level was associated with decreasing odds of severe thinness (secondary: OR 0.74; 95% CI, 0.57-0.96 and Higher: OR 0.54; 95% CI, 0.32-0.91, compared with no education); household wealth and caste were also associated with severe thinness.

CONCLUSION

This paper reveals the geographic pockets that need priority focus for managing severe thinness among pregnant women and mothers in India to limit the immediate and intergenerational adverse consequences emanating from these deprivations.

Pregnancies in women with Turner Syndrome: A retrospective multicentre UK study

OBJECTIVE

To determine the characteristics and outcomes of pregnancy in women with Turner Syndrome DESIGN: Retrospective 20-year cohort study (2000-2020) SETTING: 16 tertiary referral maternity units in the UK POPULATION OR SAMPLE: 81 women with Turner syndrome who became pregnant METHODS: Retrospective chart analysis MAIN OUTCOME MEASURES: Mode of conception, pregnancy outcomes RESULTS: We obtained data on 127 pregnancies in 81 women with a Turner phenotype. All non-spontaneous pregnancies (54/127 (42.5%)) were by egg donation. Only 9/31 (29%) of pregnancies in women with karyotype 45,X were spontaneous, compared with 53/66 (80.3%) with mosaic karyotype 45,X/46,XX (p<0.0001). Women with mosaic 45,X/46,XX were younger at first pregnancy by 5.5-8.5 years compared to other TS-karyotype groups (p<0.001), and more likely to have a spontaneous menarche (75.8% vs 50% or less, p=0.008). There were 17 miscarriages, 3 terminations of pregnancy, 2 stillbirths and 105 livebirths. Two women had aortic dissection (2.5%); both were 45,X karyotype, with bicuspid aortic valves and ovum donation pregnancies, one died. Another woman had an aortic root replacement within six months of delivery. 10/106 (9.4%) births with gestational age data were preterm and 22/96 (22.9%) with singleton birthweight/gestational age data weighed <10^th centile. The caesarean section rate was 72/107 (67.3%). In only 73/127 (57.4%) of pregnancies was there documentation of cardiovascular imaging within 24 months prior to conceiving.

CONCLUSIONS

Pregnancy in women with TS is associated with major maternal cardiovascular risks and deserve thorough cardiovascular assessment and counselling prior to assisted or spontaneous pregnancy managed by a specialist team.

Screening and management options for severe thinness during pregnancy in India

This paper answers research questions on screening and management of severe thinness in pregnancy, approaches that may potentially work in India, and what more is needed for implementing these approaches at scale. A desk review of studies in the last decade in South Asian countries was carried out collating evidence on six sets of strategies like balanced energy supplementation (BEP) alone and in combination with other interventions like nutrition education. Policies and guidelines from South Asian countries were reviewed to understand the approaches being used. A 10-point grid covering public health dimensions covered by World Health Organization and others was created for discussion with policymakers and implementers, and review of government documents sourced from Ministry of Health and Family Welfare. Eighteen studies were shortlisted covering Bangladesh, India, Nepal, and Pakistan. BEP for longer duration, preconception initiation of supplementation, and better pre-supplementation body mass index (BMI) positively influenced birthweight. Multiple micronutrient supplementation was more effective in improving gestational weight gain among women with better pre-supplementation BMI. Behavior change communication and nutrition education showed positive outcomes on dietary practices like higher dietary diversity. Among South Asian countries, Sri Lanka and Nepal are the only two countries to have management of maternal thinness in their country guidelines. India has at least nine variations of supplementary foods and three variations of full meals for pregnant women, which can be modified to meet additional nutritional needs of those severely thin. Under the National Nutrition Mission, almost all of the globally recommended maternal nutrition interventions are covered, but the challenge of reaching, identifying, and managing cases of maternal severe thinness persists. This paper provides four actions for addressing maternal severe thinness through available public health programs, infrastructure, and human resources.

The Natural History of Trisomy 21: Outcome Data from a Large Tertiary Referral Centre

OBJECTIVE

The aim of the study was to prospectively gather data on pregnancy outcomes of prenatally diagnosed trisomy 21 (T21) in a large tertiary referral centre.

METHODS

Data were gathered prospectively in a large tertiary referral centre over 5 years from 2013 to 2017 inclusively. Baseline demographic and pregnancy outcome data were recorded on an anonymized computerized database.

RESULTS

There were 1,836 congenital anomalies diagnosed in the study period including 8.9% (n = 165) cases of T21. 79% (n = 131) were age 35 or older at diagnosis. 79/113 (69.9%) women chose a termination of pregnancy (TOP) following a diagnosis of T21. Amongst pregnancies that continued, there were 4 second-trimester miscarriages (4/34, 11.7%), 9 stillbirths (9/34, 26.4%), and 1 neonatal death, giving an overall pregnancy and neonatal loss rate of 14/34 (41.1%).

CONCLUSION

The risk of foetal loss in prenatally diagnosed T21 is high at 38% with an overall pregnancy loss rate of 41.1%. This information may be of benefit when counselling couples who are faced with a diagnosis of T21 particularly in the context of limited access to TOP.

FIGO (international Federation of Gynecology and obstetrics) initiative on fetal growth: best practice advice for screening, diagnosis, and management of fetal growth restriction

Fetal growth restriction (FGR) is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction. Worldwide, FGR is a leading cause of stillbirth, neonatal mortality, and short- and long-term morbidity. Ongoing advances in clinical care, especially in definitions, diagnosis, and management of FGR, require efforts to effectively translate these changes to the wide range of obstetric care providers. This article highlights agreements based on current research in the diagnosis and management of FGR, and the areas that need more research to provide further clarification of recommendations. The purpose of this article is to provide a comprehensive summary of available evidence along with practical recommendations concerning the care of pregnancies at risk of or complicated by FGR, with the overall goal to decrease the risk of stillbirth and neonatal mortality and morbidity associated with this condition. To achieve these goals, FIGO (the International Federation of Gynecology and Obstetrics) brought together international experts to review and summarize current knowledge of FGR. This summary is directed at multiple stakeholders, including healthcare providers, healthcare delivery organizations and providers, FIGO member societies, and professional organizations. Recognizing the variation in the resources and expertise available for the management of FGR in different countries or regions, this article attempts to take into consideration the unique aspects of antenatal care in low-resource settings (labelled “LRS” in the recommendations). This was achieved by collaboration with authors and FIGO member societies from low-resource settings such as India, Sub-Saharan Africa, the Middle East, and Latin America.

Comparing three-dimensional models of placenta accreta spectrum with surgical findings

OBJECTIVE

Placenta accreta spectrum (PAS) is associated with significant maternal morbidity mainly related to blood loss. Pre-operative planning is aided by antenatal ultrasound and magnetic resonance imaging. We sought to assess whether three-dimensional (3D) models from MR images were accurate when compared with surgical and pathological findings.

METHODS

Digital Imaging and Communications in Medicine files containing MR images with varying severity of PAS (n = 4) were modeled using 3D Slicer. Placenta, bladder, and myometrial defects were modeled. Myometrial defects at three different uterine locations were included-anterior, lateral and inferior. 3D models were used to identify the relationship between the myometrial defect and the internal cervical os. Findings were validated in a larger series of PAS cases (n = 14) where patterns of invasion were compared with estimated blood loss and distance from defect to the internal os.

RESULTS

The defect illustrated in the four 3D models correlates to both surgical and pathological findings in terms of depth and pattern of invasion, location of defect, bladder involvement. Blood loss and topography of the defect from 3D modeling were examined in 14 further cases. Inferior defects were associated with increased blood loss compared with anterior defects. Increased distance from cervix was associated with reduced blood loss (R²  = 0.352, P = 0.01).

CONCLUSION

Three-dimensional models of PAS provide an accurate preoperative description of placental invasion and should be investigated as a tool for selecting patients for uterine-conserving surgery. Accurate 3D models of placenta accreta spectrum are achievable and may provide additional information, such as distance of the defect from the internal os.

Correlation of maternal body mass index with umbilical artery Doppler in pregnancies complicated by fetal growth restriction and associated outcomes

OBJECTIVE

To evaluate the correlation between umbilical artery (UA) Doppler and its feasibility across categories of maternal body mass index (BMI; calculated as weight in kilograms divided by the square of height in meters) in the presence of fetal growth restriction (FGR).

METHODS

A total of 1074 singleton pregnancies with suspected FGR on ultrasound examination between 24⁺⁰ and 36⁺⁰ weeks of pregnancy were reviewed. Evaluation of the UA Doppler was performed at 1- to 2-weekly intervals. Abnormal UA Doppler findings and delivery outcomes were compared between the different maternal BMI categories.

RESULTS

Increased UA pulsatility index (PI >95th centile) was reported in 81% of obese class II patients (BMI 35-39.9) compared with a 46% incidence in the remaining categories, normal (BMI <24.9), overweight (BMI 25-29.9), and obese class I (BMI 30-34.9) (P = 0.001). In absent or reversed end diastolic flow (AEDF/REDF) we found an increasing incidence across the BMI categories (4%-25%) (P < 0.001). Higher maternal BMI was associated with lower birthweights and higher cesarean section rates. Increasing maternal BMI did not affect successful assessment of UA Doppler.

CONCLUSION

There is a positive correlation between increasing maternal BMI and abnormal UA Doppler findings in FGR. Maternal BMI may be considered as an additional risk factor when evaluating UA Doppler for placental insufficiency.

ENDOCRINOLOGY IN THE TIME OF COVID-19: Diagnosis and management of gestational diabetes mellitus

The COVID-19 pandemic has required rapid transformation and adaptation of healthcare services. Women with gestational diabetes mellitus (GDM) are one of the largest high-risk groups accessing antenatal care. In reformulating the care offered to those with GDM, there is a need to balance the sometimes competing requirement of lowering the risk of direct viral transmission against the potential adverse impact of service changes. We suggest pragmatic options for screening of GDM in a pandemic setting based on blood tests, and risk calculators applied to underlying risk factors. Alternative models for antenatal care provision for women with GDM, including targeting high-risk groups, early lifestyle interventions and remote monitoring are provided. Testing options and their timing for postpartum screening in women who had GDM are also considered. Our suggestions are only applicable in a pandemic scenario, and usual guidelines and care pathways should be re-implemented as soon as possible and appropriate.

P208 A multidisciplinary approach to reproductive healthcare in women with rheumatic disease

Background

Rheumatic disease (RD) patients when family planning must consider fertility, disease activity, and management from preconception to lactation. A clear understanding is necessary, especially for those receiving disease-modifying antirheumatic medications. Previous studies have highlighted unmet needs in the care of women with RDs with reproductive healthcare needs. This study describes, to our knowledge, the first published standardised reproductive care pathway for women with RDs and the outcomes of this approach.

Methods

We developed the care pathway with multidisciplinary input from rheumatologists, rheumatology nurse specialists, obstetricians, midwives, maternal medicine specialists, and pharmacists. We identified patients’ emotional and healthcare needs, ensured access to expert advice, maintenance of good disease control, and positive reproductive outcomes. We prospectively followed the patients and report the results of the service.

Results

Ninety-eight women with median age (range) of 35 years (19-48) were assessed. The majority had an inflammatory arthritis. Seventy-six babies were born to 62 mothers. There were 12 miscarriages and one perinatal death. Breastfeeding rates at 6 weeks were low (28%).

Conclusion

We describe the first published evidence-based integrated multidisciplinary reproductive care pathway for women with RDs and the results of this approach. Seventy percent of women successful in trying to conceive delivered a healthy baby, and 90% of patients were ‘very satisfied’ with the service.

Disclosures

K. Murray: None. L. Moore: None. C. O'Brien: None. A. Clohessy: None. C. Brophy: None. F. McAuliffe: None. D. Veale: None.

Study protocol for a randomised trial for atosiban versus placebo in threatened preterm birth: the APOSTEL 8 study

INTRODUCTION

Preterm birth complicates >15 million pregnancies annually worldwide. In many countries, women who present with signs of preterm labour are treated with tocolytics for 48 hours. Although this delays birth, it has never been shown to improve neonatal outcome. In 2015, the WHO stated that the use of tocolytics should be reconsidered and that large placebo-controlled studies to evaluate the effectiveness of tocolytics are urgently needed.

METHODS AND ANALYSIS

We designed an international, multicentre, randomised, double-blinded, placebo-controlled clinical trial. Women with threatened preterm birth (gestational age 30-34 weeks), defined as uterine contractions with (1) a cervical length of < 15 mm or (2) a cervical length of 15-30 mm and a positive fibronectin test or (3) in centres where cervical length measurement is not part of the local protocol: a positive fibronectin test or insulin-like growth factor binding protein-1 (Actim-Partus test) or (4) ruptured membranes, will be randomly allocated to treatment with atosiban or placebo for 48 hours. The primary outcome is a composite of perinatal mortality and severe neonatal morbidity. Analysis will be by intention to treat. A sample size of 1514 participants (757 per group) will detect a reduction in adverse neonatal outcome from 10% to 6% (alpha 0.05, beta 0.2). A cost-effectiveness analysis will be performed from a societal perspective.

ETHICS AND DISSEMINATION

This study has been approved by the Research Ethics Committee (REC) of the Amsterdam University Medical Centres, location AMC, as well as the REC's in Dublin and the UK. The results will be presented at conferences and published in a peer-reviewed journal. Participants will be informed about the results.

TRIAL REGISTRATION NUMBER

Nederlands Trial Register (Trial NL6469).

Questionnaire survey on women's views after a first caesarean delivery in two tertiary centres in Ireland and their preference for involvement in a future randomised trial on mode of birth

OBJECTIVE

To assess the views of women after a first caesarean section (CS) on their birth experience, preference for future mode of birth and willingness to participate in a randomised controlled trial on mode of birth in a future pregnancy.

DESIGN

Questionnaire survey.

SETTING

Two tertiary maternity centres Ireland, Galway University Hospital, Galwayand the National Maternity Hospital, Dublin.

PARTICIPANTS

Women with one previous CS.

METHODS

Eligible women consented to participate, and postal surveys were forwarded. Results were collected and analysed. Results were compared between women who had elective operations and women who had emergency operations.

PRIMARY OUTCOME MEASURES

The satisfaction levels of women after a first caesarean, their preference for mode of birth in a future pregnancy and their willingness to participate in a randomised trial on mode of birth.

RESULTS

There were 347 completed surveys of 633 women who consented to participate (54.8%), of whom 285 and 62 had emergency and elective caesarean deliveries, respectively. In general, satisfaction ratings with the delivery were greater than 90%, with similar levels of satisfaction with the care received from doctors and midwives. Women who an emergency procedure expressed lower satisfaction levels with the information about the caesarean and the debriefing received afterwards than women who had a planned operation (p<0.05). For future mode of birth, 39.5% expressed a preference for vaginal birth after caesarean (VBAC) in a subsequent pregnancy, and 80% said they would consider involvement in a randomised trial in a future pregnancy.

CONCLUSION

Debriefing and counselling women after a CS is an important part of pregnancy care and can significantly impact on a woman's overall birth experience. A significant proportion of this cohort considered VBAC as a future birth option. These data indicate that a randomised trial on mode of birth after caesarean would be viewed positively by women in our population.

The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: A pragmatic guide for first-trimester screening and prevention

Pre‐eclampsia (PE) is a multisystem disorder that typically affects 2%–5% of pregnant women and is one of the leading causes of maternal and perinatal morbidity and mortality, especially when the condition is of early onset. Globally, 76 000 women and 500 000 babies die each year from this disorder. Furthermore, women in low‐resource countries are at a higher risk of developing PE compared with those in high‐resource countries. Although a complete understanding of the pathogenesis of PE remains unclear, the current theory suggests a two‐stage process. The first stage is caused by shallow invasion of the trophoblast, resulting in inadequate remodeling of the spiral arteries. This is presumed to lead to the second stage, which involves the maternal response to endothelial dysfunction and imbalance between angiogenic and antiangiogenic factors, resulting in the clinical features of the disorder. Accurate prediction and uniform prevention continue to elude us. The quest to effectively predict PE in the first trimester of pregnancy is fueled by the desire to identify women who are at high risk of developing PE, so that necessary measures can be initiated early enough to improve placentation and thus prevent or at least reduce the frequency of its occurrence. Furthermore, identification of an “at risk” group will allow tailored prenatal surveillance to anticipate and recognize the onset of the clinical syndrome and manage it promptly. PE has been previously defined as the onset of hypertension accompanied by significant proteinuria after 20 weeks of gestation. Recently, the definition of PE has been broadened. Now the internationally agreed definition of PE is the one proposed by the International Society for the Study of Hypertension in Pregnancy (ISSHP). According to the ISSHP, PE is defined as systolic blood pressure at ≥140 mm Hg and/or diastolic blood pressure at ≥90 mm Hg on at least two occasions measured 4 hours apart in previously normotensive women and is accompanied by one or more of the following new‐onset conditions at or after 20 weeks of gestation: 1.Proteinuria (i.e. ≥30 mg/mol protein:creatinine ratio; ≥300 mg/24 hour; or ≥2 + dipstick); 2.Evidence of other maternal organ dysfunction, including: acute kidney injury (creatinine ≥90 μmol/L; 1 mg/dL); liver involvement (elevated transaminases, e.g. alanine aminotransferase or aspartate aminotransferase >40 IU/L) with or without right upper quadrant or epigastric abdominal pain; neurological complications (e.g. eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, and persistent visual scotomata); or hematological complications (thrombocytopenia–platelet count <150 000/μL, disseminated intravascular coagulation, hemolysis); or 3.Uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth). It is well established that a number of maternal risk factors are associated with the development of PE: advanced maternal age; nulliparity; previous history of PE; short and long interpregnancy interval; use of assisted reproductive technologies; family history of PE; obesity; Afro‐Caribbean and South Asian racial origin; co‐morbid medical conditions including hyperglycemia in pregnancy; pre‐existing chronic hypertension; renal disease; and autoimmune diseases, such as systemic lupus erythematosus and antiphospholipid syndrome. These risk factors have been described by various professional organizations for the identification of women at risk of PE; however, this approach to screening is inadequate for effective prediction of PE. PE can be subclassified into: 1.Early‐onset PE (with delivery at <34+0 weeks of gestation); 2.Preterm PE (with delivery at <37+0 weeks of gestation); 3.Late‐onset PE (with delivery at ≥34+0 weeks of gestation); 4.Term PE (with delivery at ≥37+0 weeks of gestation). These subclassifications are not mutually exclusive. Early‐onset PE is associated with a much higher risk of short‐ and long‐term maternal and perinatal morbidity and mortality. Obstetricians managing women with preterm PE are faced with the challenge of balancing the need to achieve fetal maturation in utero with the risks to the mother and fetus of continuing the pregnancy longer. These risks include progression to eclampsia, development of placental abruption and HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome. On the other hand, preterm delivery is associated with higher infant mortality rates and increased morbidity resulting from small for gestational age (SGA), thrombocytopenia, bronchopulmonary dysplasia, cerebral palsy, and an increased risk of various chronic diseases in adult life, particularly type 2 diabetes, cardiovascular disease, and obesity. Women who have experienced PE may also face additional health problems in later life, as the condition is associated with an increased risk of death from future cardiovascular disease, hypertension, stroke, renal impairment, metabolic syndrome, and diabetes. The life expectancy of women who developed preterm PE is reduced on average by 10 years. There is also significant impact on the infants in the long term, such as increased risks of insulin resistance, diabetes mellitus, coronary artery disease, and hypertension in infants born to pre‐eclamptic women. The International Federation of Gynecology and Obstetrics (FIGO) brought together international experts to discuss and evaluate current knowledge on PE and develop a document to frame the issues and suggest key actions to address the health burden posed by PE. FIGO's objectives, as outlined in this document, are: (1) To raise awareness of the links between PE and poor maternal and perinatal outcomes, as well as to the future health risks to mother and offspring, and demand a clearly defined global health agenda to tackle this issue; and (2) To create a consensus document that provides guidance for the first‐trimester screening and prevention of preterm PE, and to disseminate and encourage its use. Based on high‐quality evidence, the document outlines current global standards for the first‐trimester screening and prevention of preterm PE, which is in line with FIGO good clinical practice advice on first trimester screening and prevention of pre‐eclampsia in singleton pregnancy.1 It provides both the best and the most pragmatic recommendations according to the level of acceptability, feasibility, and ease of implementation that have the potential to produce the most significant impact in different resource settings. Suggestions are provided for a variety of different regional and resource settings based on their financial, human, and infrastructure resources, as well as for research priorities to bridge the current knowledge and evidence gap. To deal with the issue of PE, FIGO recommends the following: Public health focus: There should be greater international attention given to PE and to the links between maternal health and noncommunicable diseases (NCDs) on the Sustainable Developmental Goals agenda. Public health measures to increase awareness, access, affordability, and acceptance of preconception counselling, and prenatal and postnatal services for women of reproductive age should be prioritized. Greater efforts are required to raise awareness of the benefits of early prenatal visits targeted at reproductive‐aged women, particularly in low‐resource countries. Universal screening: All pregnant women should be screened for preterm PE during early pregnancy by the first‐trimester combined test with maternal risk factors and biomarkers as a one‐step procedure. The risk calculator is available free of charge at https://fetalmedicine.org/research/assess/preeclampsia. FIGO encourages all countries and its member associations to adopt and promote strategies to ensure this. The best combined test is one that includes maternal risk factors, measurements of mean arterial pressure (MAP), serum placental growth factor (PLGF), and uterine artery pulsatility index (UTPI). Where it is not possible to measure PLGF and/or UTPI, the baseline screening test should be a combination of maternal risk factors with MAP, and not maternal risk factors alone. If maternal serum pregnancy‐associated plasma protein A (PAPP‐A) is measured for routine first‐trimester screening for fetal aneuploidies, the result can be included for PE risk assessment. Variations to the full combined test would lead to a reduction in the performance screening. A woman is considered high risk when the risk is 1 in 100 or more based on the first‐trimester combined test with maternal risk factors, MAP, PLGF, and UTPI. Contingent screening: Where resources are limited, routine screening for preterm PE by maternal factors and MAP in all pregnancies and reserving measurements of PLGF and UTPI for a subgroup of the population (selected on the basis of the risk derived from screening by maternal factors and MAP) can be considered. Prophylactic measures: Following first‐trimester screening for preterm PE, women identified at high risk should receive aspirin prophylaxis commencing at 11–14+6 weeks of gestation at a dose of ~150 mg to be taken every night until 36 weeks of gestation, when delivery occurs, or when PE is diagnosed. Low‐dose aspirin should not be prescribed to all pregnant women. In women with low calcium intake (<800 mg/d), either calcium replacement (≤1 g elemental calcium/d) or calcium supplementation (1.5–2 g elemental calcium/d) may reduce the burden of both early‐ and late‐onset PE.

Defining the upper limit of the second stage of labor in nulliparous patients

BACKGROUND

Increased duration of the second stage of labor provides clinical challenges in decision-making regarding the optimal mode of delivery that minimizes maternal and neonatal morbidity.

OBJECTIVE

In a large cohort of uncomplicated nulliparous singleton cephalic labors, we sought to examine the effect of increasing duration of second stage on delivery and perinatal outcome.

STUDY DESIGN

The GENESIS Study recruited 2336 nulliparous patients with vertex presentation in a prospective double-blinded study to examine prenatal and intrapartum predictors of delivery. Metrics included maternal demographics, duration of second stage, mode of delivery, and associated maternal and neonatal outcomes. Indicators of morbidity included third- or fourth-degree tear, postpartum hemorrhage, neonatal intensive care unit admission, low Apgar scores, cord pH <7.20 and a composite of birth injury that included cephalohematoma, fetal laceration, brachial plexus palsy, facial nerve palsy, and fetal fracture.

RESULTS

Of 2336 recruited nulliparous participants, 1872 reached the second stage of labor and had complete data for analysis. Increased maternal age (P=.02) and birthweight (P<.001) were found to be associated with a longer second stage. Increasing second stage duration was found to impact on mode of delivery, such that at <1 hour duration the spontaneous vaginal delivery rate was 63% vs 24% at >3 hours (P<.001). Operative vaginal delivery increased from 35% at <1 hour to 65% at >3 hours (P<.001). The rate of cesarean delivery increased with duration of the second stage from 1.2% at <1 hour to 11% at >3 hours (P<.001). The rates of third- or fourth-degree tear increased with second stage duration (P=.003), as did postpartum hemorrhage (P<.001). The composite neonatal birth injury rate increased from 1.8% at <1 hour to 3.4% at >3 hours. The maximum rate of birth injury was 6.5% at 2-3 hours (P<.001). Multiple logistic regression analysis that controlled for maternal age and birthweight confirmed that operative vaginal delivery, perineal trauma, postpartum hemorrhage, and neonatal birth injury remained significantly more likely with increasing second stage duration.

CONCLUSION

In a prospective cohort of nulliparous pregnancies, increasing duration of second stage of labor was associated with increased rates of operative vaginal and cesarean delivery. Although almost 90% of term nulliparous women with a second stage of labor >3 hours will succeed in achieving a vaginal birth, this success comes at a maternal morbidity cost, with a 10% risk of severe perineal injury and an increasing rate of significant neonatal injury.

Social, biological, behavioural and psychological factors related to physical activity during early pregnancy in the Screening for Pregnancy Endpoints (Cork, Ireland) cohort study

OBJECTIVE

The aim of this study was to identify the social, biological, behavioural and psychological factors related to physical activity (PA) in early pregnancy.

DESIGN

This is a secondary analysis of data from a prospective cohort study.

SETTING

The study was conducted in Cork, Ireland.

PARTICIPANTS

Nulliparous women with singleton pregnancies were recruited and then interviewed at 15±1 weeks' gestation.

PRIMARY AND SECONDARY OUTCOMES

The biopsychosocial model identified factors including social (age), biological (body mass index), behavioural (diet) and psychological (anxiety) at 15±1 weeks' gestation. PA subgroups were identified based on a latent class analysis of their responses to a set of questions about the amount and intensity of activity they were engaging in during the pregnancy. Associations were estimated with multivariable multinomial logistic regression models.

RESULTS

From a total of 2579, 1774 (69%) women were recruited; ages ranged from 17 to 45 years. Based on a combination of model fit, theoretical interpretability and classification quality, the latent class analyses identified three PA subgroups: low PA (n=393), moderate PA (n=960) and high PA (n=413). The fully adjusted model suggests non-smokers, and consumers of fruit and vegetables were more likely to be in the high PA subgroup (vs low). Women with more than 12 years of schooling and a higher socioeconomic status were more likely to be in the moderate PA subgroup (vs low).

CONCLUSION

The findings highlight potential links between PA, a low education level and a low socioeconomic background. These factors should be considered for future interventions to improve low PA levels during pregnancy.

TRIAL REGISTRATION NUMBER

ACTRN 12607000551493.

Fetal growth trajectories and their association with maternal and child characteristics

Background: The growth of the fetus is a complex process, influenced by genetic and environmental factors. Longitudinal patterns of fetal growth are required to fully understand this process, however to date, a paucity of data exists in this area.Objective: To identify fetal growth trajectories in-utero and to assess their association with maternal and child characteristics up to 5 years postnatal.Methods: Data from 781 mother-child pairs from the ROLO longitudinal birth cohort study were analyzed. The ROLO study was a randomized control trial of a low glycemic index diet in pregnancy to prevent recurrence of macrosomia. Fetal ultrasound measurements were recorded at 20 and 34 weeks gestation, and birth weight was recorded. Abdominal circumference (AC), weight (fetal weight, or birth weight), a standardized proxy for length (femur length or birth length, individually standardized), and AC:length ratio were examined for trajectory classes using latent class trajectory mixture models. Two-, three-, four-, and five-class models were evaluated for fit, using a linear (first order) trajectory over three time-points. ANOVA and chi-square tests were applied to test associations between trajectory membership and maternal and child characteristics up to age 5.Results: For AC, two fetal growth trajectories were identified, with 29% of participants on a "slow" trajectory and 71% on a "fast" trajectory. Those on a fast trajectory had higher rates of maternal impaired glucose tolerance (28.7 versus 16.5%, p<.001) and higher rates of mean child 5-year body mass index (BMI) centiles (64th versus 58th centile, p<.05) compared to those on the slow trajectory. For estimated fetal weight, four trajectories were identified, with 4% on a "very-slow" trajectory, 63% in a "moderate-slow" trajectory, 30% in a "moderate-fast" trajectory and 3% on a "very-fast" trajectory. Mothers with a fetus on the fastest trajectory had higher antenatal serum glucose levels (p<.05), and were more likely to deliver by cesarean section (59.1 versus 20%, p<.001). At 5 years of age, children on the fastest growth trajectory had the highest mean BMI centile (86th versus 60th centile, p<.05).Conclusions: This study shows that specific fetal growth trajectories may be associated with maternal serum glucose concentrations during pregnancy, mode of delivery and child BMI at 5 years of age. Diet and lifestyle measures that target maternal glucose levels during pregnancy may have lifelong benefits for children's BMI. Identifying those on an accelerated growth trajectory during fetal life provides a unique opportunity for antenatal and infant interventions that may have long-lasting health benefits.

Rituximab - A novel therapy for severe ITP in pregnancy: A case report

Background

Rituximab is a novel second-line agent for the treatment of immune thrombocytopenic purpura. Minimal data exist on the use of rituximab in pregnancy. This case illustrates the successful treatment of severe immune thrombocytopenic purpura diagnosed in pregnancy, refractory to all other medical management.

Case

A 32-year-old nulliparous woman was diagnosed with severe immune thrombocytopenic purpura at the time of booking for antenatal care (platelet level of 13 × 10⁹/L). Standard treatment failed to adequately increase her platelet count. Therapy with rituximab was instituted, and her platelet count rose to normal levels, without side effects, and remained at a normal level throughout the pregnancy. There were no maternal or neonatal ill-effects of rituximab therapy.

Conclusion

Rituximab is potentially a safe treatment option for the management of immune thrombocytopenic purpura in pregnancy with good maternal and neonatal outcome when conventional treatments have been unsuccessful. Research is limited to case reports, and therefore limited information currently exists to guide clinicians.

Effects of antenatal diet and physical activity on maternal and fetal outcomes: individual patient data meta-analysis and health economic evaluation

BACKGROUND

Diet- and physical activity-based interventions in pregnancy have the potential to alter maternal and child outcomes.

OBJECTIVES

To assess whether or not the effects of diet and lifestyle interventions vary in subgroups of women, based on maternal body mass index (BMI), age, parity, Caucasian ethnicity and underlying medical condition(s), by undertaking an individual patient data (IPD) meta-analysis. We also evaluated the association of gestational weight gain (GWG) with adverse pregnancy outcomes and assessed the cost-effectiveness of the interventions.

DATA SOURCES

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects and Health Technology Assessment database were searched from October 2013 to March 2015 (to update a previous search).

REVIEW METHODS

Researchers from the International Weight Management in Pregnancy Collaborative Network shared the primary data. For each intervention type and outcome, we performed a two-step IPD random-effects meta-analysis, for all women (except underweight) combined and for each subgroup of interest, to obtain summary estimates of effects and 95% confidence intervals (CIs), and synthesised the differences in effects between subgroups. In the first stage, we fitted a linear regression adjusted for baseline (for continuous outcomes) or a logistic regression model (for binary outcomes) in each study separately; estimates were combined across studies using random-effects meta-analysis models. We quantified the relationship between weight gain and complications, and undertook a decision-analytic model-based economic evaluation to assess the cost-effectiveness of the interventions.

RESULTS

Diet and lifestyle interventions reduced GWG by an average of 0.70 kg (95% CI -0.92 to -0.48 kg; 33 studies, 9320 women). The effects on composite maternal outcome [summary odds ratio (OR) 0.90, 95% CI 0.79 to 1.03; 24 studies, 8852 women] and composite fetal/neonatal outcome (summary OR 0.94, 95% CI 0.83 to 1.08; 18 studies, 7981 women) were not significant. The effect did not vary with baseline BMI, age, ethnicity, parity or underlying medical conditions for GWG, and composite maternal and fetal outcomes. Lifestyle interventions reduce Caesarean sections (OR 0.91, 95% CI 0.83 to 0.99), but not other individual maternal outcomes such as gestational diabetes mellitus (OR 0.89, 95% CI 0.72 to 1.10), pre-eclampsia or pregnancy-induced hypertension (OR 0.95, 95% CI 0.78 to 1.16) and preterm birth (OR 0.94, 95% CI 0.78 to 1.13). There was no significant effect on fetal outcomes. The interventions were not cost-effective. GWG, including adherence to the Institute of Medicine-recommended targets, was not associated with a reduction in complications. Predictors of GWG were maternal age (summary estimate -0.10 kg, 95% CI -0.14 to -0.06 kg) and multiparity (summary estimate -0.73 kg, 95% CI -1.24 to -0.23 kg).

LIMITATIONS

The findings were limited by the lack of standardisation in the components of intervention, residual heterogeneity in effects across studies for most analyses and the unavailability of IPD in some studies.

CONCLUSION

Diet and lifestyle interventions in pregnancy are clinically effective in reducing GWG irrespective of risk factors, with no effects on composite maternal and fetal outcomes.

FUTURE WORK

The differential effects of lifestyle interventions on individual pregnancy outcomes need evaluation.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42013003804.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Prediction of cesarean delivery in the term nulliparous woman: results from the prospective, multicenter Genesis study

BACKGROUND

In contemporary practice many nulliparous women require intervention during childbirth such as operative vaginal delivery or cesarean delivery (CD). Despite the knowledge that the increasing rate of CD is associated with increasing maternal age, obesity and larger infant birthweight, we lack a reliable method to predict the requirement for such potentially hazardous obstetric procedures during labor and delivery. This issue is important, as there are greater rates of morbidity and mortality associated with unplanned CD performed in labor compared with scheduled CDs. A prediction algorithm to identify women at risk of an unplanned CD could help reduced labor associated morbidity.

OBJECTIVE

In this primary analysis of the Genesis study, our objective was to prospectively assess the use of prenatally determined, maternal and fetal, anthropomorphic, clinical, and ultrasound features to develop a predictive tool for unplanned CD in the term nulliparous woman, before the onset of labor.

MATERIALS AND METHODS

The Genesis study recruited 2336 nulliparous women with a vertex presentation between 39+0 and 40+6 weeks' gestation in a prospective multicenter national study to examine predictors of CD. At recruitment, a detailed clinical evaluation and ultrasound assessment were performed. To reduce bias from knowledge of these data potentially influencing mode of delivery, women, midwives, and obstetricians were blinded to the ultrasound data. All hypothetical prenatal risk factors for unplanned CD were assessed as a composite. Multiple logistic regression analysis and mathematical modeling was used to develop a risk evaluation tool for CD in nulliparous women. Continuous predictors were standardized using z scores.

RESULTS

From a total enrolled cohort of 2336 nulliparous participants, 491 (21%) had an unplanned CD. Five parameters were determined to be the best combined predictors of CD. These were advancing maternal age (odds ratio [OR], 1.21; 95% confidence interval [CI], 1.09 to 1.34), shorter maternal height (OR, 1.72; 95% CI, 1.52 to 1.93), increasing body mass index (OR, 1.29; 95% CI, 1.17 to 1.43), larger fetal abdominal circumference (OR, 1.23; 95% CI, 1.1 to 1.38), and larger fetal head circumference (OR, 1.27; 95% CI, 1.14 to 1.42). A nomogram was developed to provide an individualized risk assessment to predict CD in clinical practice, with excellent calibration and discriminative ability (Kolmogorov-Smirnov, D statistic, 0.29; 95% CI, 0.28 to 0.30) with a misclassification rate of 0.21 (95% CI, 0.19 to 0.25).

CONCLUSION

Five parameters (maternal age, body mass index, height, fetal abdominal circumference, and fetal head circumference) can, in combination, be used to better determine the overall risk of CD in nulliparous women at term. A risk score can be used to inform women of their individualized probability of CD. This risk tool may be useful for reassuring most women regarding their likely success at achieving an uncomplicated vaginal delivery as well as selecting those patients with such a high risk for CD that they should avoid a trial of labor. Such a risk tool has the potential to greatly improve planning hospital service needs and minimizing patient risk.

Fetal anhydramnios following maternal non-steroidal anti-inflammatory drug use in pregnancy

We present a case report of transient fetal anhydramnios following maternal non-steroidal anti-inflammatory drug use in pregnancy. This reduction in liquor volume resolved following cessation of the medication with no obvious ill-effect on neonatal outcome. The case report is followed by a comprehensive summary of the relevant literature.

Child Care Exposure Influences Childhood Adiposity at 2 Years: Analysis from the ROLO Study

BACKGROUND

The first 2 years of life are instrumental for childhood physical development. Factors contributing to childhood obesity are difficult to determine; child care exposure is one to consider, by influencing food preference and physical activity development.

OBJECTIVE

To investigate the association of child care exposure with adiposity at 2 years.

METHODS

Data were collected as part of the secondary analysis of the prospective ROLO study (randomized control trial of low glycemic index diet) in Dublin, Ireland. Mothers were recruited antenatally and followed up at 2 years postpartum. Maternal and childhood anthropometric data and lifestyle questionnaires, reporting on child care attendance (defined as nonparental care), exposure (weeks), and infant-feeding practices, were collected.

RESULTS

Anthropometric measures and lifestyle data were collected for 273 mothers and children aged 2 years, 52.7% of whom attended child care. Child care was predominately provided by a nonrelative (83.7%), either in a crèche (57%) or by a childminder (26.7%). More than half (56.2%) of the children attended child care part-time (≤30 hours/week). Central adiposity measures (abdominal circumference, waist:height ratio) and total adiposity (sum of all skin folds) were significantly elevated in children with increasing time in child care. Children provided with "meals and snacks" had elevated adiposity measures versus those given "snacks or no food." No difference in the infant-feeding practices was identified between the child care groups.

CONCLUSIONS

Children attending child care have higher total and central adiposity, proportional to exposure. More research is required to investigate this link to appropriately design health promotion and obesity prevention programs targeting children at 2 years.

The effects of dietary and lifestyle interventions among pregnant women who are overweight or obese on longer-term maternal and early childhood outcomes: protocol for an individual participant data (IPD) meta-analysis

BACKGROUND

The aim of this individual participant data meta-analysis (IPDMA) is to evaluate the effects of dietary and lifestyle interventions among pregnant women who are overweight or obese on later maternal and early childhood outcomes at ages 3-5 years.

METHODS/DESIGN

We will build on the established International Weight Management in Pregnancy (i-WIP) IPD Collaborative Network, having identified researchers who have conducted randomised dietary and lifestyle interventions among pregnant women who are overweight or obese, and where ongoing childhood follow-up of participants has been or is being undertaken. The primary maternal outcome is a diagnosis of maternal metabolic syndrome. The primary childhood outcome is BMI above 90%. We have identified 7 relevant trials, involving 5425 women who were overweight or obese during pregnancy, with approximately 3544 women and children with follow-up assessments available for inclusion in the meta-analysis.

DISCUSSION

The proposed IPDMA provides an opportunity to evaluate the effect of dietary and lifestyle interventions among pregnant women who are overweight or obese on later maternal and early childhood health outcomes, including risk of obesity. This knowledge is essential to effectively translate research findings into clinical practice and public health policy.

SYSTEMATIC REVIEW REGISTRATION

This IPD has been prospectively registered (PROSPERO), ID number CRD42016047165 .

Holoprosencephaly: antenatal and postnatal diagnosis and outcome

OBJECTIVES

The objectives of this study are to ascertain the clinical outcome and overall survival of holoprosencephaly (HPE) patients diagnosed antenatally and postnatally, to determine the accuracy of antenatal diagnosis and to determine the role of neurosurgical intervention in HPE.

DESIGN

This is a retrospective review over a 10-year period.

PATIENTS

Sixty-three patients were included in the study, 45 were diagnosed by antenatal radiological imaging and 18 were diagnosed by postnatal radiological imaging. Patient data was drawn from Temple Street Children's University Hospital (the national paediatric neurosurgery centre), the National Maternity Hospital in Holle's Street, Dublin, and Our Lady of Sick Children Hospital, Dublin.

METHODS

The study was carried out through a review of antenatal and postnatal radiological imaging and reports, clinical charts, GP letters from patient follow-up and telephone conversations with parents of HPE patients.

RESULTS

Four patients in the antenatal diagnosis group had follow-up foetal MRI confirming HPE. Twelve in this group had radiological follow-up postnatally, and in five of these, HPE was confirmed. The remaining seven were identified as false positive. Alobar HPE constituted 55 % (21/38) of patients with 95 % mortality. Fifty-one percent had a normal karyotype. The overall survival in the antenatal diagnosis group was 13 %. In the postnatal group, 18 patients were identified, 67 % (12/18) lobar and 33 % (6/18) semilobar. Normal karyotype was found in 72 % (13/18), with an overall survival rate of 56 % (10/18). Neurosurgical intervention in both groups mainly consisted of CSF diversion in the form of ventriculoperitoneal (VP) or cystoperitoneal shunt (CP) (13/67).

CONCLUSION

Foetal MRI should be routinely performed in suspected cases of HPE, and reliance on ultrasound alone in the antenatal period may not be sufficient. In our study, there is a high early mortality noted in severe cases of HPE, while milder forms of HPE in children tend to survive beyond infancy albeit with associated complications that required neurosurgical intervention and medical management for other associated systemic anomalies.